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WORKS ON DENTISTRY 

PUBLISHED BY 

LINDSAY AND BLAKISTON. 



Harris's Principles and Practice of Dental Surgery. Eighth 
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Bond's Practical Treatise on Dental Medicine, as connected 
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Flagg on Ether in Surgery, &c. Cloth. $1. Preparing. 



A MANUAL 



EXTRACTING TEETH 



founded ox the anatomy of the parts involved in the 
operation; the kinds and proper construction of 
the instruments to be used; the accidents 
liable to occur from the operation, 
and the proper remedies to re- 
trieve such accidents. 




BY 

ABRAHAM ROBERTSON, D.D.S., M.D. 

AUTHOR OF PRIZE ESSAY ON EXTRACTING TEETH, ETC. 



PHILADELPHIA: 

LINDSAY & BLAKISTON. 

1863. 



/fr 



up 






Entered according to Act of Congress in the year 1863, by 

LINDSAY & BLAKISTON, 

in the Clerk's Office of the District Court of the United States for the 
Eastern District of Pennsylvania. 



^ 4 x to 3 



HENRY B. A.SH3IE1D, PRINTER, 

1102 and 1104 Sansom Street. 



TO 

B. FORDYCE BARKER, M . D . , 

THE EMINENT PHYSICIAN, 

THE LEARNED AND ELOQUENT PROFESSOR, 

AS A TESTIMONIAL OF RESPECT FOR HIS ERUDITION 
AND SKILL, 

^This Little Volume 

IS AFFECTIONATELY INSCRIBED 

BY HIS FRIEND, 

THE AUTHOR. 



PREFACE. 



The operation of extracting teeth being at 
best a painful one, and one to which almost 
every individual of the more than thirty mil- 
lions of inhabitants of this country, as well as 
a large share of the remaining one thousand 
millions of the human race are necessarily sub- 
jected, and millions of them many times each ; 
the interests, the comfort of humanity demand 
that those who perform the operation should be 
so instructed as to be able to do it in the most 
skillful manner. And, strange as it may seem, 
the author of this is not aware that there is any 
work, in any language, devoted exclusively to 
that subject. All, so far as he knows, that has 



viii PREFACE. 

been written on the subject, being comprised in 
a few minor articles in the dental journals, and 
an occasional chapter in treatises on practical 
dentistry — works but little likely to fall into 
the hands of the great mass of those whose duty 
requires them to perform this operation. 

Having for a long time felt the necessity of 
such a work, by having seen the evil conse- 
quences to patients for want of skill on the 
part of the operator; and having often expe- 
rienced, in his early career, the anxiety and 
trepidation of being obliged to perform opera- 
tions in the principles of which he was not fully 
instructed, the author, after an experience of 
many years, has, in this little manual, under- 
taken to set forth, as clearly as possible, all the 
principles involved in the operation ; as well as 
the necessary manipulations required ; founded 
on the anatomy of the parts concerned; the. 
proper construction of the appropriate instru- 



PREFACE. IX 

ments to be used ; and the best means of re- 
trieving the accidents liable to occur in perform- 
ing the operation. 

If in this undertaking it shall prove that he 
has contributed something toward the relief of 
the pains and sufferings of humanity, he will 
congratulate himself with the belief that he has 
not lived and laboured in vain. 

ABR. ROBERTSON. 

Wheeling, West Virginia, 
October 1st, 1863. 



CONTENTS. 



CHAPTER I. 

INTRODUCTORY REMARKS, 13 

CHAPTER II. 

ANATOMY OF THE JAWS AND TEETH, .... 18 

CHAPTER III. 

PATHOLOGY OF TOOTHACHE, . . . , . 48 

CHAPTER IV. 

INSTRUMENTS USED FOR EXTRACTING TEETH, AND THE 

PROPER METHOD OF USING THEM, ... 97 

CHAPTER V. 

OF LANCING THE GUMS, 147 

CHAPTER VI. 

ACCIDENTS ATTENDANT UPON THE EXTRACTION OF TEETH, 

AND THEIR REMEDIES, 153 

CHAPTER VII. 

ANAESTHETICS, . 193 



A TREATISE 



EXTRACTING TEETH. 



CHAPTER I. 

INTRODUCTORY REMARKS. 

The operation of extracting decayed and painful 
teeth has been performed, in some manner, from 
very remote antiquity. At first, and for many ages, 
for want of the necessary anatomical knowledge, 
and probably for various other reasons, it was per- 
formed with very unsuitable instruments and in the 
roughest and most barbarous manner. Justice also 
compels us to admit that but comparatively slight 
improvements had been made, either in the instru- 
ments used in the operation or in the manner of 
using them, till after the lapse of the first quarter 
2 



14 INTRODUCTORY REMARKS. 

of the present century, although great advances had 
been made in the knowledge of anatomy previous 
to that time. And we are compelled, in honesty and 
in sorrow further to say, that very many still, who 
extract teeth, have made but very little advance on 
the most primitive instruments or the application of 
them, although the anatomy of the human system 
has now been studied, almost to the counting of the 
hairs and fibres of the whole organization. This 
may probably be accounted for from the fact that 
anatomy has not been studied w T ith especial refer- 
ence to this particular object. But another and a 
stronger reason is, that in times past, and not very 
remote, extracting of the teeth, with bleeding, cup- 
ping, and leeching, and, indeed, most other surgical 
operations, was consigned to the care of barbers, as 
not worthy the attention of learned physicians. 
From this degradation it has not yet altogether 
recovered. But, happily for humanity, it is not now 
generally considered beneath the dignity of the wisest 
and the best, to do anything that will relieve suffer- 
ing mortals from the severest torments "to which 
flesh is heir." 

But, as what has been done badly, or is badly 
done, has but little to do with what should be done 



INTRODUCTORY REMARKS. 15 

well, or is well done, we will spend no time in de- 
scribing either those primitive instruments or the 
primitive manner of using them. The curious can 
find them described in other volumes. 

But, as this operation is more frequently performed 
than any, or than all other surgical operations com- 
bined, almost every individual in this country of ma- 
ture age, having been obliged to submit to it more or 
less repeatedly, and, as it is usually accompanied 
with more dread than any other operation of equal 
importance, and as it is always (unless anesthetics 
are used) a painful operation ; and when unskillfully 
performed, a very painful one, and sometimes even a 
dangerous one, it is therefore important that it should 
always be done in the most careful and most skillful 
manner. And, what we now propose to do, is to de- 
scribe and illustrate the instruments best adapted to 
the perfect accomplishment of the object under con- 
sideration—the entire removal of every tooth and 
root of a tooth that requires extraction, with the 
least exertion, with the least amount of force by the 
operator, with the least possible injury to tlie sur- 
rounding parts, and consequently with the least 
amount of present pain and after suffering to the 
patient ; and the most appropriate methods of ap- 



16 INTRODUCTORY REMARKS. 

plying and using such instruments to effect such 
results. 

But, before attempting to use or to apply any in- 
struments for the extraction of the teeth, preliminary 
knowledge is indispensably requisite ; to wit : a dis- 
tinct and definite knowledge of the anatomy of the 
teeth, in at least so far as their external forms and 
articulations are concerned, and of the jaws,-*— their 
articulations and appendages. A knowledge too of 
the pathology of the teeth is no less necessary and 
indispensable rightly to qualify one to perform the 
duties of this branch of surgery. 

A knowledge of anatomy can best be acquired in 
the dissecting room ; and perfectly only there. The 
author would therefore most urgently recommend to 
every one who intends devoting himself to the allevia- 
tion of the pains of his fellow beings by extracting 
their teeth, there, to seek this knowledge ; for with- 
out it, sad mistakes and injuries are liable to be com- 
mitted with the very best of instruments. 

This knowledge is necessary, not only to enable 
one to know when and how to operate, and to guard 
against the occurrence of accidents and injuries, but 
if, as is sometimes unavoidably the case in the hands 
of the most skillful, — an accident does happen, it is 



INTRODUCTORY REMARKS. IT 

still more necessary to enable him to make the best 
possible amends. For a knowledge of the anatomy 
of the parts involved, is the foundation of all surgery, 
and the only thing that enables one knowingly, and 
therefore the most effectually, to repair such acci- 
dents. 

Since then a knowledge of the anatomy of the 
teeth is a sine qua non in even learning to extract 
them, and as all may not be able to study it in the 
dissecting room, we will devote a preliminary chapter 
to that subject. 



2* 



CHAPTER II. 

ANATOMY OF THE JAWS AND TEETH. 

Sec. 1. The jaws are two, upper and lower (or 
superior and inferior). The upper jaw, entire, is 
composed of the two superior maxillary bones which 
unite at the medial line of the face. They each consist 
of what is called a body and four processes — the nasal, 
molar, alveolar, and palate process — and give form 
to the anterior middle portion of the face, and help 
to form the nose, the orbit, the cheek, and the palate. 
The body of the bone is of an irregular triangular form. 
Its interior is hollowed into a large triangular, but 
in size and form irregular, cavity called the antrum 
maxillare, or antrum highmoranium ; on the internal 
surface of which are numerous small grooves for the 
lodgment of the superior maxillary nerve and its 
branches; and in its floor are sometimes found seve- 
ral conical processes corresponding to the fangs of the 
molar teeth, which occasionally penetrate this cavity. 
This bone has four faces or sides. The external or 



ANATOMY OF THE JAWS AND TEETH. 



19 



facial which is the anterior part of the bone, the in- 
terior or nasal, the superior or orbital, and the pos- 
terior or zygomatic. 



Fig. 1. 




Fig. 1. a The body of the left superior maxilla; b Canine fossa; c 
Infra-orbital foramen; d Incisive fossa; e Harmonial suture of the 
two bones ; f Nasal spine ; g Semilunar notch of anterior nares ; h 
Nasal process ; i Articulation with lachrymal bone ; j Malar process ; 
k Tuberosity of superior maxilla; I Cavity of the antrum; m Lach- 
rymal tubercle ; n Orbital process. • 

Near the centre of the irregular concave facial 
surface is a deep depression called the canine fossa 
which gives attachment to certain muscles of the 
mouth and nose, and immediately above this fossa is 
the infraorbital foramen, which transmits what re- 
mains of the superior maxillary nerve after having 
supplied branches to all the teeth — a branch to each 
root or fang — in the upper jaw. There are other 



20 ANATOMY OF THE JAWS AND TEETH. 

fossae or corrugations of this face of the bone which 
give attachment to other muscles ; but, as they are 
not important to our present purpose, we shall not 
describe them. 

The nasal surface forms a portion of the opening 
of the nose, and articulates with the lachrymal, eth- 
moid, and palate bone. 

The superior or orbital surface is thin and triangu- 
lar and forms the floor of the orbit and roof of the 
antrum maxillare. 

The posterior or zygomatic surface is bounded an- 
teriorly by the malar process, and interiorly by a 
rough rounded border called the tuberosity, which is 
pierced by several small foramina which give passage 
to the posterior dental nerves and the superior den- 
tal artery. The lower part of this tuberosity articu- 
lates by a rough rounded surface with the palate 
bone. 

The four processes of this bone, as already named, 
are the nasal, malar, palate, and alveolar. 

The nasal process forms the lateral boundary of 
the nose, and articulates with the nasal and frontal 
bones. 

The malar .process is large and irregular, and is at 
the angle of separation between the facial and zygo- 



ANATOMY OF THE JAWS AND TEETH. 



21 



matic surfaces, and articulates by a large triangular 
surface, with the malar bone. 

The palate process projects horizontally inward 
from the inner surface of the body of the bone. It 
is thick and strong, and is concave, both above and 
below, and forms the floor of the nares and a part 
of the roof of the palate. 

The alveolar process forms the lower margin of 
the bone. Its exterior is dense and firm, its interior 
cellular. It contains in its whole length, a series of 
cells or cavities, into which the teeth are articu- 
lated, corresponding in number, size, form, and 
depth, to the number, size, form, and length of the 
fangs or roots of the teeth in the jaw. 
Fig. 2. 




This process is much thicker where it arises from 
the body of the bone, than at its free margins, at the 
necks of the teeth. Here it is thin ; sometimes very 



22 ANATOMY OF THE JAWS AND TEETH. 

thin and sharp. The septa between the cells con- 
taining the roots of individual teeth, and between 
the different teeth, are thicker or thinner according 
as the roots are divergent or close, or as the teeth 
are near or far apart. 

In the bottom of each of these alveolar cells is a 
small perforation, or foramen, for the transmission 
of a nerve and artery to, and returning vein from, 
the root of a tooth contained in it. 

The lower jaw is the largest bone of the face; and 
although it consists of two distinct symmetrical 
halves in the foetus, is but one bone in the adult ; 
united by a ridge, at the centre, or that part which 
forms the chin, which is called the symphysis. It is of 
a semi-circular, or more nearly, of a horse-shoe shape ; 
extends from the chin to the base of the skull, where 
it articulates with the glenoid fossae of the temporal 
bone. It gives form to the lower part of the face. 
It is divided into a body and rami. The body is the 
horizontal portion, and on both its external and 
internal surfaces are various protuberances or pro- 
cesses, and indentations, or fossae, which afford 
attachments to the muscles of the lips and tongue ; 
but, as in extracting the teeth, we have but little to 
do with any muscles except those which close the 
jaws, we shall not stop now to describe them. 



ANATOMY OF THE JAWS AND TEETH. 23 

About the middle of the bone, and just below the 
fangs of the canine teeth, are the mental — sometimes 

Fig. 3. 




Fig. 3. The inferior maxilla : a Body of the bone ; b Mental fora- 
men; c The symphysis; d d Alveolar processes ; e Ramus of the lower 
jaw ; / Its angle ; g g Coronoid processes ; h h Sigmoid notch ; i i Con- 
dyloid processes; j j Neck of the condyles; h Inferior dental foramen; 
I Mylo-hyoid ridge. 

called the anterior mental — foramina, which afford 
exit to the inferior dental nerve and artery, after 
each having supplied a branch to each root of a tooth 
contained in the jaw. The upper edge of the jaw is 
surmounted by the alveolar processes and cells, cor- 
responding, like those in the upper jaw, in number, 



24 ANATOMY OF THE JAWS AND TEETH. 

size, form and depth, to the number, size, form and 
length of the roots of the teeth which they contain and 

Fig. 4. 




support. These processes are wanting, mostly, in 
foetal life, and early infancy ; and in old age, or at 
an earlier period, with the loss of the teeth, are 
gradually wasted or absorbed away ; coming with 
the teeth and departing with them. 

The anterior alveolar processes are thinner and 
higher than the posterior ; the roots of the wisdom 
teeth being almost entirely imbedded in the body of 
the bone, or haying at most, a very short and thick 
process ; a matter of great practical importance, as 
we shall see, when treating of the extraction of the 
lower wisdom teeth. 

The ramus of the jaw is a strong, oblong-shaped, 
process, rising from the posterior portion of each side 



ANATOMY OF THE JAWS AND TEETH. 



25 



of the body, forming an angle more or less obtuse, 
according to the time of life of the individual, In 

Fig. 5. 




foetal life and in infancy, being very obtuse or almost 
horizontal with the body of the bone. In youth 5 
and till mature manhood, it slowly advances toward 
a perpendicular position, or right angle. After the 
loss of the teeth, in old age, it is said again to de- 
cline. The upper portion of the ramus is divided 
into two processes, by a broad fissure, called the 
sigmoid notch. (See Fig. 3.) 
3 



26 ANATOMY OF THE JAWS AND TEETH. 

These processes are called the coronoid process, and 
the condyle of the lower jaw. The anterior, or 
coronoid process, is broad at its base, rather thin, of 
a triangular shape, and affords attachment to the 
temporal muscle. The posterior, or condyle of the 
jaw, is flattened from before backward, and is 
smooth on its top to form its hinge-like articula- 
tion. 

Near the centre of the internal surface of the 
ramus is the inferior dental foramen, through which 
the inferior dental artery and nerve enter the jaw, 
and are transmitted through the body of the bone 
below the alveolar cells (each of which, like those in 
the upper jaw, is perforated by a minute foramen 
for the transmission of a branch of each to its con- 
tained root of a tooth, and for the egress of the 
recurrent vein) to the mental foramen, where they 
pass out to be distributed on the chin. The posterior 
junction of the ramus with the body of the bone 
forms a rough tuberosity called the angle of the 
jaw. 

Sec. 2. The muscles that are chiefly concerned in 
the extraction of the teeth, and more particularly in 
the accidents that may sometimes occur in connec- 



ANATOMY OF THE JAWS AND TEETH. 



27 



tion with that operation, and therefore require our 
present attention, are the temporal, the masseter, 
and the external and internal pterygoid muscles. 
These are the elevators of the lower jaw, and also 
give it its forward and backward, and its lateral 
motions. 

The upper jaw has no independent motion. It 
only moves with the motions of the whole head. 

Fig. 6. 




Fig. 6. g Zygomaticus minor; h Zygomaticus major: i Masseter 
muscle; r Deep-seated portion of masseter. 



The masseter is a short, thick, quadrilateral shaped 
muscle. It arises from the tuberosity of the superior 



28 



ANATOMY OF THE JAWS AND TEETH. 



maxillary bone, the lower margin of the malar bone, 
and from the zygoma, and is inserted into the ramus 
and angle of the lower jaw. 

The temporal is a broad, radiating muscle, occupy- 
ing a large part of the side of the head. It arises 

Fig. 7. 




Fig. 7. a Side view of the temporal muscle, exposed by the removal 
of the temporal fascia ; b External lateral ligament of the lower jaw; 
c Insertion of temporal muscle into coronoid process of lower jaw. 



from the whole length of the temporal ridge, from 
the temporal fascia, and from the entire surface of 
the temporal fossa. Its fibres converge to a narrow, 
but strong tendon, which is inserted into the apex of 



ANATOMY OF THE JAWS AND THKTH. 



29 



the coronoid process, and from some distance down 
its inner surface. 

The internal pterygoid (Fig. 7,) is a thick quid 



Fig. 8. 




Fig. 8. a and 6 Superior and inferior portions of the pterygoideus 
externus : c Pterygoideus internus ; d Hoot of zygomatic process ; 
e Condyle. 

The ramus is cut away to show the internal pterygoid muscle. 

rangular muscle. It arises from the pterygoid fossa, 
and descending obliquely backward, is inserted into 
the ramus and angle of the lower jaw. From its 



30 ANATOMY OF THE JAWS AND TEETH. 

resemblance to the masseter, in appearance and di- 
rection, it has sometimes been called the internal 
masseter. 

The external pterygoid is a short, thick, triangular 
muscle, being broader at its origin than at its inser- 
tion, (a, b, Fig. 8.) It arises from the pterygoid 
process, pterygoid plate, and the tuberosity of the 
palate bone. It passes backward, and is inserted 
into the neck of the lower jaw and its capsular liga- 
ment. 

The office of the pterygoid muscles, when acting 
separately, is to give the lateral, or grinding, motion 
to the jaw. When acting together, they thrust the 
jaw forward, and close the mouth. 

Sec. 3. Anatomy of the Teeth. 

Man, in common with most other animals, is sup- 
plied with two complete and distinct sets of teeth. 
A temporary and a permanent set. 

In mankind, the temporary set, called also decidu- 
ous or milk teeth, consists of twenty teeth; ten in 
each jaw. They are of the sizes, forms, and struc- 
ture suited to the size of the jaw T s, and to the 
necessities of infancy and childhood. When by the 
absorption of their roots they are loosened, and drop 



ANATOMY OF THE JAWS AND TEETH. 31 

out, or are removed, their places are supplied by 
another, a larger and a stronger set, suited to the 
increased size of the jaws and to the wants of ma- 
ture life. 

The temporary set is divided into three classes: 
incisors, of which there are four in each jaw; canine 
teeth, or cuspidati, two in each jaw; and molars, or 
grinding teeth, four in each jaw. 

The roots of the temporary molars are generally 
broader and thinner, and more divergent, according 
to their size, than the corresponding permanent 
ones; and as this is the only material difference be- 
tween them, or any other of the corresponding 
classes of the two sets, except the much smaller size 
of the temporary, a particular description of their 
forms is here unnecessary. 

The permanent set consists of thirty two teeth; 
sixteen in each jaw. They are divided into four 
classes, each having very distinct and definite forms ; 
to wit : four incisors, two canine or cuspidati, four 
bicuspidati, or small molars, and six molars in each 
jaw. The incisors, for convenience of description, 
are, from their positions, subdivided into right and 
left, central, and lateral incisors. The bicuspidati, 
into first and second, or anterior and posterior, right 



32 ANATOMY OF THE JAWS AND TEETH. 

and left ; and the molars, into first, second and third, 
right and left molars ; always reckoning from the 
front backward. The third molars are also called 
dentes sapientiae or wisdom teeth ; from their coming 
later in life. They vary greatly in the time of their 
coming ; sometimes appearing as early as sixteen 
years of age, and sometimes not before thirty-five. 

The length, width and thickness of all the teeth, 
and the curvatures of the crowns of the incisors, 
vary materially in different individuals, according to 
the configurations of the persons to whom they be- 
long. Thus, tall, slender persons, usually have 
comparatively long and narrow teeth, while short, 
thick set persons have shorter, broader and thicker 
teeth. Short thick set persons too, usually have 
thicker bones and alveolar processes than those with 
more slender forms. Their teeth are generally more 
firmly set, and therefore, require more force to effect 
their removal. 

The color of the teeth varies too, in different in- 
dividuals, from an almost pearly white, to a deep 
tinge of yellow, or of brown, or blue, closely corres- 
ponding with the complexion of the individual. 
Their color varies, too, with the age of the indi- 
vidual, from light in youth, to dark in age. 



ANATOMY OF THE JAWS AND TEETH. 33 
\ 

Their density, strength, and durability is also very 
variable. Cachectic and lymphatic persons mostly 
having thin, soft, frail teeth, while the robust and 
healthy have thicker, denser, stronger and more 
durable ones. Their density varies, too, with the 
age of the person ; being much more solid in age 
than in youth. 

Each tooth, for convenience of description, is di- 
vided into three parts : the crown, the neck, and the 
root or roots. The crown extends from the edge of 
the cutting, or the grinding surface, as the case may 
be, to the gum ; or is that part which is exposed to 
view, and is covered by the enamel. 

The neck is the slightly constricted portion next 
to the crown, and extends, when the parts are in a 
normal condition, from the edge of the gum to the 
edge of the alveolus, or perhaps more strictly, from 
the crown to the bifurcation in the molar teeth. 

The root, or fang, is that part of the tooth con- 
tained within the alveolar cell or socket, and articu- 
lates it with the jaw. 

Although the crowns of the same class of teeth 
vary very much in form and size, in different in- 
dividuals, a general outline of the description of any 
tooth belonging to a given class will be the same. 



34 



ANATOMY OF THE JAWS AND TEETH. 



The superior central incisors occupy the anterior 
central portion of the upper jaw; one on each side 
of the mesial line of the face. Their crowns are of an 
oblong, quadrilateral form, averaging about five lines in 
length by four in width ; and usually a little wider at 
their free, or cutting edges, than at the gum, or necks 
of the teeth. Their cutting edges are nearly straight 

Fig. 7. 




across, though their corners are sometimes slightly 
rounded, and especially their outer corners. Their 
anterior, or labial surfaces, are always more or less 
convex ; while their inner or posterior surfaces are 
correspondingly concave ; the interior surface form- 
ing the segment of a smaller circle than the outer. 
The tooth is much thicker at the gum than at its 
edge, and presents an appearance as if it had been 
formed into a wedge, by cutting away the inner sur- 
face of the tooth, and then slightly bending it in- 
ward, with a regular curve from the neck to the edge, 



ANATOMY OF THE JAWS AND TEETH. 35 

The roots of these teeth average about seven lines in 
length, and about three lines in diameter. They 
are irregularly conical in shape, tapering, somewhat 
unevenly, to their points ; and the outer portion form- 
ing the segment of a rather^ larger circle than the 
inner. 

The lateral incisors are next in order to the cen- 
trals. Their crowns are usually a little shorter than 
those of the centrals, in the same mouth, and about 
three-fourths their width. Their corners are more 
rounded than those of the centrals, and especially 
their outer corners, which are generally considerably 
so. Their roots, though slightly shorter, are very 
nearly of the same length as the others, but are 
generally considerably more flattened, or compressed, 
laterally, than they. The outer portion, like the 
centrals, is larger than the inner. 

Next to the lateral incisors are the cuspidati or 
canine teeth ; one on each side. The crowns of these 
are about the same length and width as the central 
incisors ; but they are thicker at their necks, from 
their outer to their inner surfaces, and stronger than 
the incisors, and instead of being like them broad and 
straight across their edges, they are tapered for about 
half their length to a blunt spear-like shaped point. 



36 



ANATOMY OF THE JAWS AND TEETH. 



They are also more convex on their labial surfaces, 
and but slightly, if at all, concave on their internal 
or lingual surfaces. From their greater thickness 
they stand a little more prominent than the other 



Fig. 8. 




teeth, forming approximations to corners in the den- 
tal arch. Their roots are both larger and longer 
than those of any of the other teeth, being most com- 
monly a line or more longer than those of the central 
incisors. Their roots are also shaped differently 
from those of any of the other teeth, for they are 
not only larger at their neck, but they taper to 
more slender points. They are, though sometimes 
almost perfectly round, usually about once and a half 
as large in their antero-posterior diameter as in their 
approximal, with the appearance of having been com- 
pressed or flattened like the roots of the upper lateral 
and all the lower incisors. A transverse section of 



ANATOMY OF THE JAWS AND TEETH. 



37 



the root presents an ovoid form, though the outer or 
larger portion of the root would generally be a little 
larger, and the smaller or inner portion a little 
smaller in proportion, than a longitudinal section of 
an egg. The roots of these teeth are more fre- 
quently curved, in part, or all of their length, and 
more subject to have short crooks in them, and are 
generally more closely and firmly articulated with 
the alveolus, and therefore require more force for 
their removal, than any other of the single-rooted 
teeth. 

All the incisors and cuspidati of both jaws, the 
second or posterior bicuspidati of the upper jaw, and 
all of the bicuspidati in the lower jaw have each 
uniformly but one root. 

The upper bicuspidati come next in order. 

Fig. 9. 







Their crowns are a little shorter than the preceding, 
and are very nearly an ovoid shape, but somewhat com- 
4 



38 ANATOMY OF THE JAWS AND TEETH. 

pressed on their approximal sides — the larger end 
representing the grinding surface of the tooth, which 
is furrowed in the direction of the arch of the teeth 
by a broad triangular groove, thus leaving two — an 
outer and an inner — rather blunt tubercles or cusps, 
and the smaller end of the egg truncated to repre- 
sent its union with the neck of the tooth. 

The first or anterior bicuspidatus on each side, 
Fig. 10. 



fffff 



most commonly, but not uniformly, has two roots : 
an external and an internal. They are small and 
round ; sometimes regularly and increasingly diver- 
gent from their bifurcation to their points. Some- 
times they are considerably divergent for a half or 
two-thirds of their length, and then convergent till 
their points nearly, or even quite, come in contact 
with each other. Sometimes they take a course 
quite close and parallel to each other, as if they had 
been originally but one flattened root, simply split 
in two. At other times they are found having but 
one root, very much flattened on its approximal 
sides, and grooved so as to show the rudiments of 
two roots. 



ANATOMY OF THE JAWS AND TEETH. 39 

The second or posterior bicuspidati, as already re- 
marked, have uniformly but one root each, which 
is always compressed or flattened and grooved on its 
approximal sides. Their crowns are entirely similar 
to those of the anterior. The roots of all the bicus- 
pidati are of about the same length as are those of 
the incisors. 

Fig. 11. 




The upper molar teeth, three on each side, are the 
last in the order, and the largest of them all. Of 
these, the first or anterior is a little the largest, and 
the third or wisdom tooth is considerably the smallest. 

The crowns of these teeth are nearly cubical in 
shape, with their corners all rounded. In size each 
of their surfaces or faces is about equal to or a little 
larger than the face of the central incisor belonging 
to the same set. Their grinding surfaces are of 
course broad, and they are furrowed or cut by several 
triangular grooves leaving at least four or more 
tubercles or cusps. 



40 ANATOMY OF THE JAWS AND TEETH. 

They have ordinarily each three roots. Two ex- 
ternal or buccal, and one internal or palatal. The 
external roots are an anterior and a posterior. Of 
these two, the anterior is larger than the posterior, 
being indeed about twice its size, it is broad and flat, 
being compressed from before backward, and stands 
out more prominent in the arch than its fellow. The 
two stand nearly perpendicular to the outside of the 
crown, but usually diverge more or less from each 
other. The internal root is generally the longest of 
the three. Its size is about the same as that of the 
anterior external root, but instead of being flattened 
like that, it is round or nearly so. It generally di- 
verges considerably from the perpendicular of the 
crown toward the palate, but after diverging for 
about two-thirds of its length, the remaining portion 
most commonly converges toward the points of the 
other roots. Sometimes, and indeed not unfrequently, 
this and one of the other roots are united for nearly 
or quite their entire length into one broad flat root. 
This union is much more frequent with the anterior 
than with the posterior root. Sometimes too, all 
three of these roots are combined into one large irre- 
gular root, which is simply grooved so as to show the 
rudiments of the three roots. This is much the most 



ANATOMY OF THE JAWS AND TEETH. 



41 



common, indeed, quite common, in relation to the 
third molar or wisdom teeth. 

The upper wisdom teeth too are perhaps more fre- 
quently found irregular in relation to the line of the 
arch of the jaw than any other class. 

When malposition of these occur, they are gene- 
rally found with their tuberculated or grinding sur- 
faces looking toward the cheek. The roots of the 
teeth under these circumstances are usually more or 
less hook-shaped, as if the crown of the tooth had 
been seized while standing in its proper position and 

forcibly bent outw r ard. 

Fig. 12. 




The crowns of the lower incisors are of about the 
same length as are those of the upper, but much 
narrower, these being but about tw T o and a half lines 
in width. They are a little broader at their cutting 
edges than at their necks. The centrals are usually 
a very little narrower than the laterals, w 7 hile in the 
upper jaw the reverse of this always obtains 5 the cen~ 

4* 



42 



ANATOMY OF THE JAWS AND TEETH. 



trals there being much broader than the laterals. 
The roots of the centrals are a little shorter than 
their laterals. The roots of all the lower incisors 
are very much compressed or flattened on their ap- 
proximal sides. They are very nearly of the same 
length as are those of the corresponding teeth of the 
upper jaw. 

The lower canine teeth, or cuspidati, are shaped 

Fig. 13. 




very similarly to the upper, except that they are 
smaller and rather more pointed, and their roots are 
more compressed or flattened. 

The crowns of the lower bicuspidati are about of 
the same length, but a little more slender than the 
upper. In form, otherwise, they are very nearly 
the same as those, except that the inner cusp of 
these is usually smaller, and especially that of the 
first or anterior one, which frequently presents only 
the rudiment of an inner cusp. 



ANATOMY OF THE JAWS AND TEETH. 



43 



The inner cusps of both the upper and lower bi- 
cuspidati are always smaller than the outer. 




The roots of these teeth are also a little more 
compressed, and a little smaller than those of the 
corresponding upper ones. But as has already been 
remarked, these teeth have invariably but one root 
each. 

The crowns of the lower molars are so near in 




form like the upper as not to require a separate de- 
scription. 



44 ANATOMY OF THE JAWS AND TEETH. 

They have each usually two roots : an anterior 
and a posterior. They are broad and flat, and 
thinner in their central portions than at their edges. 
The anterior root is generally a little larger and 
a little longer than the posterior. They bifurcate 
just at the edge of the alveolar process ; and at that 
point usually diverge more or less extensively to 
their extremities ; though they sometimes diverge 
only for a portion of their length and then converge 
till their points nearly or quite meet ; thus enclosing 
that part of the alveolus which forms the septum be- 
tween their sockets ; which must be brought away on 
removing the tooth — a circumstance that often greatly 
complicates the operation of extraction, and always 
renders much more force necessary for that opera- 
tion. Sometimes they diverge but little — the roots 
being parallel to each other and in almost complete 
apposition. Occasionally, too, each of these roots 
are divided in their centres, for a part or all of their 
length, making four distinct roots. This, however, 
is of no practical importance in so far, at least, as 
the operation for their removal is concerned. The 
lower wisdom teeth are more frequently irregular in 
the number of their roots than any others. 

The lower wisdom teeth have also another peculi- 



ANATOMY OF THE JAWS AND TEETH. 45 

arity, which to some extent, at least so far as my 
observation has extended, is unvarying ; and which 
is of very great practical importance, as it renders 
an entirely different mode of procedure and different 
instruments necessary for their ready removal — 

Fig. 15. 




which I shall discuss more fully when treating 
of the extraction of this class of teeth, which in 
a description of the anatomy of the teeth must not 
be omitted. This peculiarity consists in the fact 
that the roots of these teeth are always more or less 
curved, sometimes almost hook-shaped, and the points 
of their roots or foramina — the point of every root 
of every tooth is pierced by a minute foramen which 
affords passage for a branch of nerve and artery 
which supply nutriment and vitality to its crown — 
pointing or looking toward the angle of the jaw. 

Sometimes the roots of any or all of the lower 
molar teeth — and sometimes too, but more rarely, 



46 



ANATOMY OF THE JAWS AND TEETH. 



those of the upper molars — are found terminating in 
small hooks, as seen in the cut. 



Fig. 16. 




The roots of the wisdom teeth are shorter than 
those of any other class. 

The teeth are held in the jaws by a kind of 
articulation peculiar to themselves, called a gom- 
phosis articulation, or like that of a nail driven 
into a board or other substance. So it is de- 
nominated, and described, by anatomists ; but in 
other words, and more exactly and more plainly, 
each root of every tooth has a cell in the alveolar 
process, corresponding in depth and form to its form 
and length. These cells, or sockets, are enough 



ANATOMY OF THE JAWS AND TEETH. 47 

larger than the contained roots of the teeth, to 
admit of their being lined by a dense, strong mem- 
brane, called the periosteum ; which is also reflected 
upon the root. This, with their roughness, their 
crooks, and their irregularity of form, and their di- 
vergences and their convergences, holds them very 
firmly in their places ; so that, when they are healthy 
and intact in all their parts, it requires a consider- 
able force to remove or displace them. 



CHAPTER III. 
PATHOLOGY OF TOOTHACHE. 

Toothache proper — (there is scarcely more pro- 
priety in calling all painful affections of the teeth, 
toothache, than there would be in calling all pains 
in the head, headache) — is usually the result of 
either caries of the teeth, or of the absorption of the 
gums and alveolar processes, or of mechanical causes 
or violence. 

Caries of the teeth is the effect of various causes : 
such as, deleterious substances coming in contact 
with, and acting chemically upon them ; hereditary 
malformations and imperfections in their organiza- 
tion and structure ; and from insufficient supply of 
the proper materials of which they are composed, 
occasioned by want of proper aliments, or an ina- 
bility to assimilate them, by reason of sickness or 
other causes, while the teeth are in the process of 
formation within the- gums and alveolar processes. 



PATHOLOGY OF TOOTHACHE. 49 

Mechanical violence, too, may be an indirect cause 
of caries of the teeth. 

The agents that act chemically upon the teeth to 
produce caries, are acids. Many other substances 
may indirectly produce this effect, by deranging the 
general health, and thus changing some of the secre- 
tions, which in a normal state are either neutral or 
alkaline, to an acid reaction. This altered secretion 
coming in contact with the teeth decomposes and 
destroys them. Still the direct agent is an acid. 
All acids act upon the teeth, when in contact with 
them, with more or less vigor, according to their kind 
and strength ; hence persons addicted to eating- 
lemons, or other strongly acid fruits, are very liable 
to suffer from caries of the teeth. 

Dyspeptics, who are troubled with great acidity of 
the stomach, and with frequent regurgitations of 
such fluid into the mouth, as is a very common 
occurrence in such cases, are almost always sufferers 
from this cause. Persons taking acids as medicines, 
without taking proper care to avoid their coming in 
contact with their teeth, or immediately to neutralize 
the acid, suffer in the same manner. 

The saliva in its normal state, including the 
saliva proper and the buccal mucus, is alkaline, 
5 



50 PATHOLOGY OF TOOTHACHE. 

The mucus is slightly acid, while the secretion of 
the glands — which is by far the most abundant secre- 
tion — is alkaline. One effect of a very large share, 
if not of most of the diseases to which humanity is 
subject, is to change the saliva from an alkaline to 
an acid reaction. Thus, during sicknesses of various 
kinds, the teeth are constantly bathed in acid and 
therefore suffer greatly. 

As medicines are usually administered during 
sickness, and as the teeth are almost uniformly 
observed to suffer at such times, the almost universal 
impression is, that all medicines injure the teeth; 
whereas all medicines, so exhibited as to restore 
health — to restore the secretions, and especially of 
the mouth, from an unhealthy to a healthy condition 
— from an acid to an alkaline reaction, protect the 
teeth from decay, instead of injuring them. 

Even the stronger mineral acids, when so care- 
lessly administered as to be allowed to come in con- 
tact with the teeth, and no care taken to neutralize 
it, though for the time it may severely injure the 
teeth, if it be not too long continued and if its effect 
be to restore the health, may even afford more pro- 
tection than injury to them. But as such medi- 
cines, used without due care, greatly injure the teeth, 



PATHOLOGY OF TOOTHACHE. 51 

great care should be taken to avoid their coining in 
contact with them, or they should be followed by 
such alkaline or antacid washes as will neutralize 
their effects. And in the topical use of some of the 
salts having acid bases, as nitrate of silver, by the 
greater affinity of its nitric acid for the lime of the 
tooth than for the silver, if allowed to come and to 
remain in contact with the teeth, will have the same 
decidedly injurious effects ; it should therefore be 
administered with the same caution. 

So too, whenever the physician is called to the 
treatment of any case where the saliva is changed 
to an acid reaction, if he would do his patient all the 
good he can, he should prescribe antacid washes to 
be frequently used with a view to the protection of 
the teeth, and care should be used, too, to see that 
this condition of the secretions is not overlooked. 

Imperfect organization of the teeth, from what- 
ever cause, subjects them to great liability to decay 
for two reasons. First, such teeth are less capa- 
ble of resisting the action of deleterious substances 
that may come in contact with them ; and secondly, 
and most especially the enamel of such teeth — does 
not perfectly cover and protect their dentine. They 



52 PATHOLOQY OF TOOTHACHE. 

have imperfections or interstices, at the lines of 
union of the different parts of the enamel where 
they approximate, and should unite, from the differ- 
ent points of deposit, affording ready lodgment 
for any free acids that may chance to be in the 
mouth, as well as for food to be forced into, by mas- 
tication, there to lie and ferment and become acid. 

Mechanical violence, as accidental fracture ; or 
chipping off small fragments of enamel, by biting 
very hard substances, as cracking nuts, and the 
like ; the use of the file, &c, has the same effect. 
They all remove more or less of the enamel, and also 
leave the surface roughened so as to afford lodg- 
ment for foreign substances, and render them diffi- 
cult to be kept clean. 

The habit of placing artificial teeth in the mouth, 
and sustaining them there by clasps, or bands, 
around other teeth, is also another great source of 
the decay of these organs ; and the broader these 
clasps are, and the more perfectly they are fitted to 
the teeth which they embrace, the more destructive 
they are ; for so much the greater and more perfect 
a lodgment do they afford for such foreign sub- 
stances, and the more perfectly do they keep them 



PATHOLOGY OF TOOTHACHE. 53 

in contact with the teeth. The bad effects, in these 
cases, are mostly chemical, and not mechanical. 
The use of clasps, therefore, is but rarely justifiable, 
and, fortunately, but very seldom necessary. 

Although caries is by far the most common cause 
of toothache, there are many other causes that pro- 
duce it, and caries itself produces several varieties of 
this most painful disorder. This, therefore, brings us 
to speak more particularly of the different 

Sec. 2. Varieties of toothache and their causes. 
For convenience and clearness of description, 
toothache may be divided into 

1. Toothache from exposure of the nerve. (I use 
the word nerve in its common acceptation, implying 
by it the whole soft internal part of the tooth ; in- 
cluding nerve, artery, vein and cellular substance, 
or as it is, by dentists, most commonly called the 
pulp of the tooth.) 

2. From inflammation of the nerve without its 
direct exposure, resulting in the formation of pus in 
the nerve canal, abscess, &c. 

3. From inflammation of its periosteum. 

4. From inflammation of its dentine. 

5* 



54 PATHOLOGY OF TOOTHACHE. 

5. From sympathy or reflex irritation — neuralgic 
toothache. 

6. From exostosis. 

7. From accidents. 

Toothache from exposure of the nerve is probably 
the most common of all the varieties. This may be 
produced by the accidental fracture of the tooth, but 
is most commonly produced by caries. 

Caries may attack a tooth in any part of its ex- 
posed, or external surface : but it does so most fre- 
quently, at the bottom of the grooves of the grinding 
surfaces of the molars in the interstices left by a 
defective union of the enamel there ; in the approxi- 
mal surfaces of any or all of the teeth ; in the ex- 
terior or labial surfaces of the incisors, and of the 
cuspidati, (and when in this surface most commonly 
just at the edge of the gum,) and often, but less fre- 
quently on the buccal surfaces of the bicuspidati and 
molar teeth, and on the lingual surfaces of the in- 
cisors and cuspidati. 

Toothache from exposure of the nerve generally 
occurs, except when caused by accident — where caries 
has progressed until but a very thin covering of 
dentine remains over the nerve, or if the caries have 
commenced, and has progressed with but a very 



PATHOLOGY OF TOOTHACHE. 55 

small orifice through the enamel, until it has quite 
reached the nerve, undermining the enamel as it pro- 
gresses, and, as often happens without causing pain, 
when by picking the teeth or masticating food, or by 
biting some hard substance, this thin shell of enamel, 
or of dentine, as the case may be, is broken in, and 
the tooth-pick, or the fragment of the tooth, or 
portion of the food, is forced upon the nerve, pro- 
ducing a sudden attack of the most excruciating pain. 
This may be alleviated or entirely relieved, for the 
time, by the removal of the foreign substance, and 
the application of any of the stronger stimulants, as 
creasote, the essential oils, or chloroform ; but the 
pain will be liable to return whenever food, hot or 
cold fluids, cold air or other foreign substances, are 
suffered to come in contact with the nerve. In this 
state they sometimes remain for weeks or even 
months, without giving much if any pain except from 
such extraneous causes ; when at length, from fre- 
quent irritations of this kind, inflammation will be 
induced, when a more continued, but still severe, 
pain will be likely to ensue. At length, if left to its 
natural course, suppuration occurs and the nerve is 
thus destroyed, when, in many cases, all pain will 
cease, and not again occur till the whole crown and 



56 PATHOLOGY OE TOOTHACHE. 

even a large share of the root is wasted by decay. 
But this is by no means the uniform result ; for 
sometimes the inflammation of the nerve extends 
through the foramen to the periosteum. This occurs 
much most frequently in the lower jaw where, pus 
formed in the canal, or food, or the fluids of the 
mouth may be carried through the foramen by the 
force of gravitation, and thus produce inflammation 
about the point of the fang. When this state occurs, 
a less acute but a more steady and annoying 
character of pain ensues, and which is liable to be 
more acute at night while warm in bed, and in a 
horizontal position, than while up during the day. 
This may be accounted for by the warmth and 
the horizontal position favoring a greater termination 
of blood to the part than an erect position. Occa- 
sionally too, from some remaining portion of the 
membranes a troublesome, painfnl, fetid fungus will 
arise, sometimes filling the whole nerve canal as well 
as the cavity caused by the decay, which will require 
the removal of the tooth. This kind of fungous 
growth may generally very readily be distinguished 
from an exposed nerve by its bright or red color, 
by its being far less sensitive, and by its free bleed- 
ing on being very slightly touched. Such bleeding 



PATHOLOGY OF TOOTHACHE. 57 

will very much reduce the size of the tumor and fre- 
quently entirely relieve the pain ; which may not 
again recur until the tumor is again formed and 
filled with blood, which however will most likely occur 
in a few days. 

In almost all cases of toothache from exposure of 
the nerve in the upper incisors and cuspidati, if the 
caries has not already so far destroyed the crowns 
of the teeth as to render the operation of filling im- 
practicable, a radical cure can be effected by early 
and efficient treatment ; and very many of these 
teeth can be restored to usefulness and health, by 
suitable treatment, even after they have been long 
neglected, and abscesses have been formed; but 
such delay greatly complicates the difficulties and 
lessens the chances of restoration. A majority of 
the upper bicuspidati, many of the upper molars, 
and some of the lower teeth may thus be saved. 
The success of the treatment, especially in the 
molars, will very much depend on the convenience, 
or the possibility, of getting at the part decayed, 
and through that to the nerve canals ; without this 
possibility all attempts at treatment must at best be 
very uncertain and most probably futile. 

In order to treat such teeth successfully, the ex- 



58 PATHOLOGY OF TOOTHACHE. 

posed nerves should be removed, either directly by 
the use of suitable instruments, or, where this is not 
practicable, by the use of caustics ; of which arseni- 
ous acid, moistened with creasote, is the most effec- 
tual and quickest in action ; from the twentieth to 
the sixteenth of a grain of which, applied on a very 
small pledget of lint or cotton, and left in contact, 
from six to twenty-four hours, being entirely suffi- 
cient, in most cases, to effect the object. Great 
care, however, should be taken in the use of arsenic 
for this purpose, to avoid letting it come in contact 
with the gums and other parts of the mouth, lest 
ulceration and sloughing be produced. Some very 
serious accidents have occurred from the incautious 
use of this article. 

After the nerve has been thus destroyed, the nerve 
canals and the cavity of decay should be thoroughly 
cleansed from all diseased dentine, pus and foreign 
substances ; or if the nerve has been destroyed, in 
the natural course of events, by suppuration, all such 
matters, and everything that might decompose and 
form either pus or gas, should be carefully cleansed 
away, and if necessary otherwise properly treated, 
and the roots and cavities carefully filled. 

The treatment of the upper teeth with a view to 



PATHOLOGY OF TOOTHACHE. 59 

their preservation by destroying their nerves, is 
much more likely to be successful than of the lower, 
as the force of gravitation is liable to bring the 
articles used for the destruction of the nerves, as 
well as particles of food and the fluids of the mouth, 
during the time of the treatment, in contact with 
the periosteum at the point of the root, thus exciting 
a troublesome and sometimes an uncontrollable in- 
flammation in that membrane. 

2. Toothache from inflammation of the nerve ivith- 
out direct exposure. 

This occurs when, from caries, the absorption of 
the gums and alveolar processes, attrition, or other 
causes, the nerve of the tooth has so far been de- 
prived of its natural protection, that the passage 
over it of hot or cold fluids, or the contact of cold 
air, produces irritation of this delicate and extremely 
sensitive structure. A tooth may, and frequently 
does, remain in this situation for a considerable 
length of time without being much, if any, trouble- 
some, except while the cause of the irritation remains, 
as while taking a draught of cold water, a cup of 
hot coffee, or the like ; but at length, after repeated 
irritations of this kind, inflammation supervenes, 
and then the real trouble commences. 



60 PATHOLOGY OF TOOTHACHE. 

When active inflammation exists in the nerve of a 
tooth so circumstanced, a steady severe pain is ex- 
perienced ; and its intensity is owing, greatly, to the 
fact that inflammation in the soft parts always pro- 
duces swelling, and as the nerve, the pulp of the 
tooth, is confined in an unyielding canal of bone, it 
is subjected, by this swelling, to a severe pressure ; 
its only means of expansion or escape being through 
the minute foramen in the point of the fang, which 
till suppuration has taken place is of no practical 
effect, as it is altogether too small to admit of integu- 
ment or membranes being forced through it. 

Usually, within twenty-four hours of the com- 
mencement of severe pain, the tooth begins to feel 
sore, and a little longer than the rest, and perhaps a 
little loose. Sometimes the tooth is so sore, from 
the inflammation of the membrane about the point 
of its root, that but a slight touch upon it, with the 
finger, will make the patient start suddenly, or even 
cry out with the pain. 

At this stage, suppuration has commenced, and the 
pus is beginning to be forced through the foramen 
of the fang. The pressure of this matter produces 
inflammation and swelling of the membranes at the 
bottom of its alveolar socket, and this raises the 



PATHOLOGY OF TOOTHACHE. 61 

tooth slightly in its socket and accounts for its ex- 
treme sensitiveness to the touch ; and particularly, 
by its contact with its fellow opposite, on closing the 
mouth. 

If the case be not now relieved, the pus, by the 
pressure within, is forced through the foramen, and 
insinuated between the point of the fang and its peri- 
osteum, forming a sac larger or smaller, from the 
size of a pin's head to that of a pea. During this 
stage the pain may dart along the course of the 
nerves, to any or all of the teeth on that side of the 
head, to the temple, the ear, or the scalp ; or to 
any part where the branches of the fifth pair of 
nerves is distributed ; that being the nerve which 
supplies the teeth with branches. The pus still 
being confined in a bony cell — the alveolar cell — the 
pressure is great and the pain severe. But soon, the 
pus forces its way through the parietes of the alveo- 
lus. Then the face begins to swell, and the pain is 
less severe and of a different character — being of that 
throbbing character which indicates the formation of 
abscess, accompanied often with considerable febrile 
excitement. 

If the difficulty be not arrested here, abscess will 
pretty certainly follow. These abscesses usually 
6 



62 PATHOLOGY OF TOOTHACHE. 

"point" on the gum, but sometimes, and not very 
unfrequently unless prevented by making a free in- 
cision through the gum, if the tooth causing it be in 
the lower jaw, and a molar, on the cheek, leaving a 
most unsightly escar ; or if the tooth be in the front 
of the mouth, under the chin. Sometimes, too, if the 
tooth happen to be a first or second molar in the 
upper jaw, and if, as sometimes happens, the roots of 
the tooth enter into, or come very near entering into, 
the antrum maxillare, the abscess will be developed 
in that sinus. 

This train of symptoms and consequences is some- 
times produced by the injudicious or careless inser- 
tion of plugs or fillings in the teeth, or a like insertion 
of an artificial tooth by pivot on a natural root. 

The proper treatment for this kind of toothache, 
as will readily be seen by this description, is either 
to expose and destroy the nerve before suppuration 
has commenced, or to give vent to the pus as soon as 
it is formed. This last can readily be done by the 
use of a very small drill, or trocar, inserted into the 
cavity caused by the caries, at the point nearest to 
the nerve canal, or if the trouble be the result of some 
other cause than caries, by trepanning the root at 
any accessible point, thus making an opening for 



PATHOLOGY OF TOOTHACHE. 63 

the escape of the pus ; and if this be done before the 
formation of the sac, and the tooth is such an one 
and so situated as to admit of having the canal or 
canals of its fang or fangs thoroughly cleansed and 
filled in the manner already described for that opera- 
tion, not only permanent relief, but the future use- 
fulness of the tooth will be secured. But after 
abscess is once formed, the case becomes much more 
complicated and uncertain, as to the results of treat- 
ment. Still, by judicious and persevering treatment, 
many cases can be cured, and others may be rendered 
useful and quite tolerable for years, even after this 
state has occurred. I have seen cases where a fistu- 
lous discharge has been kept up through the gum, 
from an old abscess, for several years, even at that 
late day, entirely restored to health. But in rela- 
tion to the success of treatment much will depend on 
the situation of the teeth, with reference to the 
facility of getting at them, and also to the extent of 
the mischief caused by the abscess. If it has caused 
much necrosis or wasting of the alveolus, or if it has 
denuded the fang, to any considerable extent, of its 
periosteum, treatment will be hopeless. For the 
fang of a tooth that is denuded of that membrane, 
beyond a very small portion of its very apex, will 



64 PATHOLOGY OF TOOTHACHE. 

lose its vitality and act as a foreign substance, keep- 
ing up a constant irritation and discharge of pus. 
And if the abscess have formed within the antrum 
maxillare, or if it have pointed on the outside of the 
cheek, or under the chin, the only prudent course 
left is to remove the tooth, and the sooner this is 
done the better. 

Although trepanning a tooth may afford relief from 
present pain and secure the future usefulness of the 
organ, if pus has formed in the nerve canal, and 
enough has been forced out to form a sac on the end 
of the root, of the size of a pin's head, it can never 
return through the foramen, to be discharged through 
the tooth ; but if the tooth is trepanned at this stage, 
so as to evacuate what is in the canal of the tooth, 
and thus relieve the pressure, that amount, or even 
much more than that, may be absorbed, and no 
abscess be developed; otherwise, that will sooner or 
later, and surely, be the result. 

Although what I have already described, is the 
usual course of the progress and development of pus 
confined in the canal of a tooth, sometimes it takes 
quite a different course of progression, but finally 
terminating in the same result. Thus, the nerve be- 
comes inflamed and suppurates, and a sac is formed of 



PATHOLOGY OF TOOTHACHE. 65 

even the size of a small pea, and the face swells 
slightly, and so remains, for, it may be, some days ; 
but at length the pain and the swelling subside, and 
entirely cease, while the sac or rather the yielding 
and protrusion that it causes in the alveolus, can be 
distinctly felt with the finger through the gum, and 
by pressure upon it a sensation of fullness is ap- 
parently felt in the tooth, and so it may remain even 
for months without giving further trouble ; but unless 
this sac be cut down upon through the gum and alve- 
olus, and the pus discharged, it will ultimately, from 
some exciting cause, as the taking of cold or exposure 
to the excitement of unduly hot or cold fluids taken 
into the mouth, be incited to renewed action, it will 
burst, and abscess be fully developed. 

Sometimes, but much more rarely, after the nerve 
of a tooth has been destroyed, either by operation or 
otherwise, the canal may become stopped with food 
or other substances, by mastication, so as to prevent 
the egress of pus through the crown of the tooth, 
and abscess be developed in the same manner as if 
the nerve had never been entirely exposed. Some- 
times, too, even when pus has ceased to be secreted, 
gas may be formed, and by being thus pent up may 
be forced through the foramen so as to produce in- 

6* 



66 PATHOLOGY OF TOOTHACHE. 

flammation and terminate in the same result. These 
are the chief and almost only causes of alveolar 
abscess, though an accident such as a severe blow on 
a tooth is said sometimes to cause it, and undoubtedly 
may do so ; but I have never yet seen one from this 
cause. Sometimes, but very rarely, an abscess may 
form from a dead root of a tooth, but generally such 
cases are simply the filling up of an old abscess 
which originated before the crown of the tooth was 
broken, of which the root remains and continues to 
act as an irritant. Generally when pus is formed 
around an old root of a tooth, it exudes between the 
root and the alveolus without forming a distinct ab- 
scess. Abscess, caused by a tooth having been de- 
cayed or denuded of its natural covering, is always 
formed at the point of its fang, or if not, I have never 
yet found the sac of an incipient abscess, nor the 
remnants of the sac of an old abscess, at any other 
point, or part, of a tooth. This I write after an ex- 
perience of more than twenty years. In that time I 
have extracted many thousands of teeth; and in the 
very commencement of my professional career I had my 
attention especially directed to this particular branch 
of their pathology, and have, therefore, observed 
them carefully, and almost constantly ever since, in 
reference to this particular point. 



PATHOLOGY OF TOOTHACHE. 67 

Inflammation of the periosteum of a tooth, instead 
of being resolved by the formation of pus, sometimes, 
and indeed often causes a deposit of lymph. This may 
be deposited at the bifurcation, or at any other part of 
the fang, and has been mistaken by some observers 
— I should rather say writers — for the remains of the 
sac of an abscess. The difference however may very 
easily be distinguished, from the patent fact that 
wherever an abscess or sac containing pus, has been 
formed, whether large or small, that part of the root 
under such sac, that is, the part where the pus lay, 
is always denuded of its investing membrane or 
periosteum ; while, in the other case, the membrane 
remains firmly attached to the root and the lymph is 
adherent to it. 

3. Toothache from inflammation of the periosteum. 

This usually occurs in the periosteum of old roots 
of teeth whose crowns are gone; or in the periosteum 
of such teeth as have had their internal membrane 
destroyed by escharotics, whose effects have extended 
beyond the pulp to that membrane ; or by the in- 
flammation caused by the exposure of the nerve, by 
neglect of proper treatmemt, having extended to that 
membrane ; or sometimes in sound teeth whose an- 



68 PATHOLOGY OF TOOTHACHE. 

tagonists have been removed, thus leaving them with- 
out the necessary exercise to keep them in a healthy 
condition ; and also by artificial teeth being attached 
to natural ones by clasps, the weight of the artificial 
ones dragging them from their sockets and loosening 
them. 

This is the kind of toothache that has sometimes 
been thought to be " epidemic !" These " epidemics" 
occur after long rain storms, or other great atmos- 
pheric changes, and as teeth in this condition are 
always liable to be affected by " taking cold," they 
are usually most troublesome after such changes ; 
and as there are always a great many of them in 
every community, such epidemics are pretty fre- 
quent. 

The pain, in this kind of toothache, is described 
as of a more dull, heavy character, and the tooth 
though sore is not so extremely sensitive to the touch 
as that last described. This kind may readily be 
distinguished from the others by observing the con- 
dition of the gum, which presents a livid appearance 
along the course of the root, with more or less swell- 
ing ; generally, however, with but little, showing a 
chronic state of inflammation. There may be a kind 
of puffiness opposite the point of the fang, and per* 



PATHOLOGY OF TOOTHACHE. 69 

haps a slight discharge of pus may ooze out by pressing 
slightly upon it with the finger. This is occasioned 
by the partial filling up of an old, and most likely 
fistulous abscess, which is a very common cause of 
this affection. There is but rarely any, or at most 
but little, swelling of the face, accompanying this 
kind of toothache. The pain, though generally not 
very severe, is very annoying, constant and trouble- 
some. It may usually be palliated by local bleed- 
ing, by holding cold water in that part of the mouth, 
or by other antiphlogistic remedies ; and if the pain 
be caused by the dragging of artificial teeth or the 
loss of the opposing teeth, a removal of the irritating 
cause and frequent friction of the gum with a brush, 
accompanied with some strongly astringent and 
stimulating wash, may effect a cure ; but if the dis- 
ease is connected with a dead tooth, or an old root, 
the only radical cure will be extraction. 

4. Toothache from inflammation of the dentine. 

This kind of toothache is produced by the use of 
the file and by caries — and much the most frequently 
by the latter — and in most cases is most severe when 
the caries has extended only through the enamel, or 
but very slightly into the dentine ; and for the 



70 PATHOLOGY OF TOOTHACHE. 

probable reason, that here, that is, at the union of 
the enamel with the dentine, is the termination of 
the nerve fibres that ramify the dentine ; the great- 
est amount of sensibility always being found in any 
part, at the termination of the nerves. This kind of 
toothache is usually developed by the contact of cold 
air, acids, sweets, or hard substances, coming in con- 
tact with the inflamed dentine ; and generally sub- 
sides when such irritant is removed, or ceases to act. 
The intensity and the persistency of pain from in- 
flammation, other things being equal, depends chiefly 
on the degree of organization or vascularity and 
vitality of the part. Dentine, having but a low grade 
of these, is not susceptible of the same degree of 
inflammation as the soft parts, or even as other bones 
which are more highly organized. 

Some teeth are much more highly organized than 
others : for example, persons of a strumous diathesis 
have softer and more highly organized teeth than 
those with better constitutions ; and children and 
youth, than those advanced in years ; hence the 
teeth of the young and those with bad constitutions 
are much more liable to suffer from inflammation of 
the dentine than those who are older, and the healthy 
and strong. 



PATHOLOGY OF TOOTHACHE. 71 

I am fully aware, in the outset, that in calling 
this affection, inflammation, I am treading on contro- 
verted ground — that many contend that dentine is 
not susceptible of true inflammation. What then is 
the cause of this sensitiveness, and this pain ? Will 
calling it "exalted sensibility," or some other name, 
change the facts or aid our understanding of them ? 
'Tis true that parts that have no circulation can 
have no inflammation. Enamel is never inflamed — 
is rarely sensitive. It is also true that dentine 
cannot manifest all the characteristics of inflamma- 
tion as manifested in the soft parts. From the 
density of its structure it is not susceptible of swell- 
ing. Neither are any of the common bones ; but 
does any body, on that account, deny their suscepti- 
bility to inflammation ? From the small amount of 
the vital fluids circulated in the teeth, they are not 
susceptible of perceptible increase of heat. Is that 
condition perceptible in inflamed bone ? Redness of 
the parts is another concomitant attending inflamma- 
tion of the soft parts, which, usually, cannot attend, 
or at least be appreciated in, inflammation of the 
dentine. Red globules of blood do not permeate 
healthy dentine ; and most writers have contended 
that they do not under any circumstances. This, 



72 PATHOLOGY OF TOOTHACHE. 

my own observation has satisfied me, is not correct. 
Some highly organized teeth — though I admit the 
cases may be rare — may, and do, circulate red blood 
when in a state of inflammation. 

In 1845, I was applied to by Miss N., a young 
lady of about eighteen years of age, of a spare habit 
and of a very marked cachectic diathesis, to fill 
several of her teeth. Each of her four upper incisors 
had a rather large cavity in its anterior or labial sur- 
face. In removing the decayed portions, preparatory 
to filling, I found the dentine extremely sensitive; 
so much so, that I was obliged to make some applica- 
tion to obtund it before I could complete the opera- 
tion. But I finally succeeded in doing it, and, for 
the time, very satisfactorily. But in two or three 
days my patient returned complaining of great pain 
in her teeth, and contended that the pressure of the 
gold within the cavities caused the pain. On ex- 
amination I found that the crown of each of them 
had a very decided tinge of red. Thinking it possi- 
ble that I might, unwittingly, have exposed or 
wounded their pulps, and that the fillings were press- 
ing npon them and causing the pain, and that 
possibly, too, blood was extravasated under the 
fillings, thus causing the redness, I removed the 



PATHOLOGY OF TOOTHACHE. 73 

fillings. This immediately gave her some relief — it 
removed the sensation of pressure that she had com- 
plained of, though it did not afford entire freedom 
from the pain. 

After removing the fillings, I made careful exami- 
nation of the cavities, but could find neither extrava- 
sated blood, or the least point of exposed membrane 
in any of them ; but the dentine over the whole sur- 
face of the cavities was quite red and very sensitive 
— much redder, of course, than it appeared when 
seen through the enamel before the fillings were re- 
moved. I made an application of morphine to the 
cavities, which I also renewed once or twice, and in 
a few days the redness and most of the sensitiveness 
had left them. I then carefully refilled them, she 
still complaining of some pain from the pressure. 

In a few days she returned again, with the teeth 
looking quite as red, or even redder than before, and 
complaining of the same kind of suffering as before, 
and, perhaps, in a greater degree. I again removed 
the fillings and applied the morphine with the same 
result as before ; and after some further treatment to 
obtund and to prevent the sensibility, I again refilled 
them, and without any recurrence of inflammatory 
symptoms. 



74 PATIIOLOGY OF TOOTHACHE. 

It is perhaps but just to remark, in connection 
with this case, that with all the care I could use in 
filling those teeth, about one year at a time was all 
that I could succeed in making fillings remain in 
them. 

Two other gentlemen in whose skill in such opera- 
tions I had great confidence, and from an observa- 
tion of the results of their work for several years, 
tried some of them once or more times each, and 
with a knowledge of the fact that I had already tried 
each of them, at least twice, and that I believed they 
could not be so filled that the operation would be 
permanent, as a further stimulant to their exertions ; 
but, to their confessed disappointment, with no better 
result. 

About four years after my first operations on her 
teeth, this young lady died of phthisis pulmonalis. 

Since my experience with this case, whatever my 
convictions might have been before, I have had no 
doubt that dentine is susceptible of inflammation, and 
that too in a pretty high degree. 

This, I am aware, is an extreme case, but it is not 
altogether an isolated one. I have seen others of a 
similar kind, but no other as bad as this. But if this 
case stood entirely alone, it would prove, to my mind, 



PATHOLOGY OF TOOTHACHE. 75 

that dentine is susceptible of inflammation, and it 
would indicate to me that the sensitiveness, so fre- 
quently observed in the teeth when but slightly de- 
cayed, is true inflammation, but only of a lower 
degree than this. But it is not necessary to resort 
to such extreme cases to establish this doctrine. 

That dentine is endowed with all the essential 
characteristics necessary for the development of in- 
flammation, as vitality, nutrition and secretion, is 
easily demonstrable. 

That it is endowed with vitality is evinced by its 
sensitiveness when in a normal state, by its greater 
sensitiveness when diseased, and by its greater pow- 
ers of resisting the influence of chemical agents, 
when in a healthy condition, than after its vitality 
has been destroyed. Dead teeth decay much more 
rapidly in the same mouth than living ones ; crowns 
of natural teeth engrafted on the roots of other 
teeth, as artificial substitutes, never last at most but 
very few years. 

That it receives nutrition, from both its internal 
membranes and from its periosteum, needs no argu 
ment now. If that is not an essential part of the 
office of both these membranes, they would seem to 
have no office ; and nature never makes or tolerates 
useless things. 



76 PATHOLOGY OF TOOTHACHE. 

That it is endowed with the function of secretion 
and reproductive — recuperative — energy to some ex- 
tent like other bones, though not, so far as known, 
to the extent of the union of fracture, has been 
abundantly proved in numerous instances by the 
filling of teeth where a portion of inflamed, softened 
and exquisitively sensitive dentine has been left in 
the bottom of the cavity, the better to protect the 
nerve of the tooth, and which by thus being protected 
from external influences, after a time, on removing 
the filling, has been found, without undue sensitive- 
ness, firm, solid and healthy. 

It is no uncommon occurrence either for a tooth 
to decay to a considerable extent, with the usual 
sensitiveness accompanying decaying dentine, and 
after a time from a change in the secretions of the 
mouth, or other circumstances, that originally caused 
the decay ; for the inflammation and sensitiveness to 
subside, the process of decomposition to cease, and 
the dentine, that had been softened, to become hard 
and sound — harder by far than ordinary healthy 
dentine, and so to remain for many years, and with- 
out any local treatment. Is not this the effect of 
recuperative vital energy ? 

I know of one case where a right central upper 
incisor commenced to decay, on its anterior or labial 



PATHOLOGY OF TOOTHACHE. 77 

surface, before the crown of the tooth was more than 
half projected from the gum ; and by the time it had 
acquired its full length the cavity was very large, 
occupying about one-fourth of the whole anterior 
surface of the tooth, and quite deep. The process 
of decomposition finally ceased, exfoliation undoubt- 
edly took place, and the tooth was restored to com- 
plete health ; the only apparent defect in it being a 
somewhat corrugated appearance, and a very slight 
discoloration of the part. And now, at more than 
forty years from the commencement of the process 
of decay, the tooth is entirely healthy and strong. 
That tooth is my own. 

That decaying dentine is susceptible to extreme 
sensitiveness and pain — most constant concomitants 
of inflammation — none can deny ; and if the affec- 
tion be not inflammation, what other appellation 
shall we use better to describe the condition ? 

In most cases this " exalted sensibility" and pain 
can be alleviated by some soothing application, or 
removed by carefully cutting away a thin layer of 
the diseased dentine, and wholly removed and pre- 
vented by cutting away all the diseased portion and 
filling the cavity with suitable materials, so as to 
prevent the contact of all irritating substances, 

7* 



78 PATHOLOGY OF TOOTHACHE. 

5. Toothache from Sympathy. 

This most commonly occurs when the nerve of one 
tooth is inflamed, from exposure or other causes, or 
its periosteum is inflamed, and the pain is referred 
to some other tooth; and that other quite as likely 
to be entirely sound as diseased. This is a circum- 
stance of very frequent occurrence when one of the 
lower wisdom teeth is in fault ; then the pain is 
quite as apt to be referred to one of the bicuspidati, 
or one of the incisors, in either jaw, on that side of 
the head, as to the tooth that is diseased. In such 
cases, too, the pain is often complained of in the 
ear, temple and scalp, and sometimes soreness of the 
scalp is also complained of. 

A careful examination will settle the point, and it 
is a good rule never to extract any tooth without 
being able to give some good reason for it, and a 
better one than that the patient wishes it done, or 
thinks that it aches. This rule, carefully observed, 
would save a great many valuable teeth from being 
simply sacrificed. 

Sometimes too, nervous irritation in other, and 
even remote parts of the system, produce pains that 
are referred to the teeth, as uterine affections, affec- 
tions of the stomach, &c. Quite recently, a very 



PATHOLOGY OF TOOTHACHE. 79 

intelligent lady related to me some of her own ex- 
perience, which forcibly illustrates this point. Some 
years ago she suffered from a very severe attack of 
toothache. She applied to her family physician for 
relief, and he, not discovering the cause of her pain, 
recommended her to a dentist. He, not observing 
the rule given above, extracted several of her teeth, 
at different times, but without affording any relief. 
And her sufferings were so intense that she said she 
believed she should have had all her teeth extracted, 
if she had not, accidentally, cured herself. She 
found herself suffering from acidity of the stomach ; 
and for that, took a dose of the carbonate of soda, 
when almost immediately, and, to her great delight, 
she found her toothache had entirely left her. And, 
several times afterward, she said, she had had tooth- 
ache from the same cause, and cured it in the same 
manner. Of course to extract a tooth expecting 
to remove the toothache produced by such causes 
would be the extreme of folly — more, it would be 
wickedness. 

A careful examination into all the circumstances 
and an application of the rule just given, must be the 
guide in all such cases. 



80 PATHOLOGY OF TOOTHACHE. 

6. Toothache from Exostosis. 

Exostosis of a tooth, is a bone-like deposit of about 
the hardness, and of an appearance similar to the 
cementum or outer portion of the roots of the tooth ; 
the cause of which is but very imperfectly, if at all, 
understood. It generally commences at, or very near, 
the point of the root, but may commence at any 
other point, and is said sometimes to have been found 
extending even to their crowns. 

The pain from this disease, when it occurs, is pro- 
bably caused by the pressure it makes on the nerve. 
Sometimes it is severe when the deposit is quite 
small, in other cases it is slight, or there may be 
none at all, even where the deposit is quite large. 

Roots of teeth are frequently found with such en- 
largements upon them that have remained in the 
mouth years after their crowns have been entirely 
removed by decay, and without giving any pain or 
cause of complaint. Whether the deposit was made 
before or after the decay of the crown, and loss of 
the nerve, is extremely difficult to determine. Of 
course after the nerve W T as gone, it could not impinge 
upon that to cause pain. But when it does cause 
pain, whatever its manner of doing it may be, 



PATHOLOGY OF TOOTHACHE. 81 

the only known source of remedy, or relief, is 
extraction. 

The diagnosis of this kind of toothache is perhaps 
more difficult and uncertain than that from any other 
cause, and particularly so where the deposit is small ; 
as the tooth then presents no external sign of dis- 
ease. When it is of considerable size, it generally 
makes a corresponding protrusion of the alveolus 
that can be felt with the finger. Probably the 
surest test, when the enlargement cannot be felt be- 
neath the gum, is rapping the tooth lightly with some 
small, hard instrument, which, if the cause of the 
pain be exostosis, will, probably, for the time increase 
it. Great caution, however, should be taken about 
extracting teeth where no other cause can be found 
than the exacerbation of pain by jarring the tooth, 
or by even very lightly touching it. It is well to re- 
member that this is not a common cause of toothache ; 
and that without such caution serious mistakes may 
be, and have been committed ; in illustration of which 
I will relate two rather marked cases. 

In the autumn of 1858, a gentleman of this city 
of about thirty years of age, came to ask my opinion, 
and advice, in relation to a very severe pain which 
he had been suffering, at intervals, for two or three 



82 PATHOLOGY OF TOOTHACHE. 

years ; and which for the last year had been so fre- 
quent, and so severe, that he had been obliged to 
relinquish a very lucrative business, luckily, however, 
on a competency. His pain and suffering he referred 
to the root of the lower canine tooth. 

On inquiring into the history of the case, I learned 
from him, that he had been suffering most intensely, 
at intervals, as already remarked, for some years. 
That the pain came on in sudden paroxysms, of which 
sometimes, he would have very frequent successions 
during several days or even weeks, and again he 
would be entirely free from them for a longer or a 
shorter period. These paroxysms seemed to be in- 
dnced from the slightest causes, as a touch of the 
tooth, or even of that part of his face, and on that 
account, sometimes for several days together, he had 
hardly been able to take food enough to sustain life ; 
and had been reduced in weight between thirty and 
forty pounds. He had once had the mental nerve 
of that side excised, with no effect, except the partial 
paralysis of his lower lip. As his trouble was in- 
creasing, and as his physicians could find no other 
cause for the pain, and especially as he so constantly 
referred it to that tooth, and as so slight a touch 
upon it brought on the paroxysms of pain, although 



PATHOLOGY OF TOOTHACHE. 83 

the tooth had no appearance of disease, they advised the 
removal of the tooth ; and about three months before 
his consulting me, he had applied to a young practi- 
tioner of dentistry to have it extracted. He attempted 
it, without success, but broke off the tooth in part at, 
and a part below the edge of the alveolus ; and, as 
he could not succeed in removing the root, decided 
that it must have exostosis of the fang, and so told 
his patient ; and that it could not be removed without 
first cutting away the alveolar process to, or near 
the point of the root, which was also represented to 
him as quite an important surgical operation. It was 
on that account chiefly that he was induced to apply 
to me. 

On hearing his account, and on a close examina- 
tion of the case, I was satisfied that it was a case of 
pure neuralgia ; that there was no exostosis, and that 
the tooth had nothing to do in causing his pain, and 
that its extraction, or any other mere local treatment, 
would probably have just as little to do with re- 
moving it, and so advised him. But I further ad- 
vised him, that as the tooth was now broken, and 
thereby rendered useless ; and as the removal of its 
root might be a relief, and satisfaction to his mind, 
he had better now have it removed ; and I assured 



84 PATHOLOGY OF TOOTHACHE. 

him, if he wished it, I could remove it without any- 
unusual difficulty. He preferred not to have it done 
just then, but said he would return in two or three 
days to have the operation performed. But meanwhile 
he was called suddenly to go to Philadelphia ; and while 
there having a severe attack of his neuralgia, he ap- 
plied to some gentleman there — I am glad I do not 
know to whom — for advice. This gentleman, pro- 
bably relying on the diagnosis of his young prede- 
cessor, who broke the tooth, determined that it was 
necessary to extract the root ; and either for an ex- 
cuse for demanding a larger fee, or some other 
unknown cause, determined that in order to enable 
him to do that, it was necessary for him first to ex- 
tract the adjoining bicuspid, which was a perfectly 
sound tooth ! This he did ! and then chiseled away 
the septum between it and the broken root, in order 
to get that out, which, when he had gotten it out, 
proved not only to have no exostosis, but to be un- 
commonly slender and pointed ! 

And worst of all, after having sacrificed two per- 
fectly sound teeth, the patient was not in the least 
relieved of his sufferings. His disease was beyond 
reasonable doubt constitutional, not local. 

While on this subject of neuralgia, as it is too 



PATHOLOGY OF TOOTHACHE. 85 

common a cause of mistakes of this kind, I will relate 
another case, analogous to this. 

In 1857 I was called in consultation with a medi- 
cal gentleman to see a young lady of about seventeen 
years of age ; small in stature, of delicate constitu- 
tion, and of nervous temperament. For several 
months she had been suffering most intensely from 
neuralgic pains, which she referred to her teeth. 
On examination I found all the teeth she then had, 
as well as her gums, and all other parts of her mouth, 
apparently in the most perfectly healthy condition ; 
but she had already had all the molars and nearly 
or quite all the bicuspaditi of both jaws extracted 
with the hope of finding relief. She now wished "to 
have, and had insisted on having, one of her upper 
canine teeth removed ; but the physician then in 
attendance, both from a knowledge of the fact that 
she had experienced no relief from the removal of the 
many that had already been sacrificed, and from the 
firm belief that she needed constitutional, and not 
local treatment, advised the asking of my opinion ; 
and, at his request, I was therefore called in 
consultation. 

I fully concurred in her physician's opinion; and 
though tearfully implored by the young lady, de- 



86 PATHOLOGY OF TOOTHACHE. 

clined to extract the tooth ; knowing, and assuring 
both her and her widowed mother, that it would be 
but a sacrifice of the tooth, without affording the least 
hope of relief. 

I am sorry here to feel compelled to add, that this 
young lady went to the gentleman who had already 
mutilated her so sadly, by taking out the most of 
those she had already lost ; and he, although he was 
aware of the opinion, at least, of her medical adviser, 
and of the fact that what he had already done had 
been of no avail, was, either through ignorance or 
cupidity or both, induced to extract the tooth, and 
of course with no better results than had attended 
his former operations. Great care then should be 
taken not to be deceived into the belief that all pain- 
ful affections referred to the teeth are toothache, and 
require the extraction of the teeth. 

But there are some affections which frequently 
come under our observation and care, and which 
often require the extraction of the teeth, that are 
not properly toothache, though generally so denomi- 
nated, of which we must not here fail to speak. 

One of the most common and painful of these is 
that caused by the cutting of the wisdom, and more 
especially of the lower wisdom, teeth. 



PATHOLOGY OF TOOTHACHE. 87 

There are several kinds of difficulty and trouble 
from this cause. One common one is owing to the 
fact that these teeth are very liable to assume irregu- 
lar positions : as for example, the grinding surface of 
the tooth, or, in such a case more properly, its multi- 
cuspidated surface, may present itself to the cheek, 
when, if its cusps happen to be pretty sharp or a 
little rough, they may produce irritation or inflam- 
mation, swelling and pain ; and on this account, 
unless a file can be brought to bear upon them, so as 
to remove such sharp or rough points, may require 
to be extracted. 

But a more common and much more troublesome 
condition is where, from the narrowness of the space 
allotted to them at the posterior portion of the jaws, 
there is not room for their full development. If, in 
such cases, the upper tooth precedes the lower for a 
considerable length of time, as frequently happens, 
so that the upper has acquired its full length ; or by 
having nothing to oppose it, perhaps a little more 
than its proper length, thus occupying more than 
its due proportion of the limited space allotted to 
both, when the lower advances near to the surface 
it raises the gum so as to bring it in contact with 
the upper tooth at every occlusion of the jaws. 



88 PATHOLOGY OF TOOTHACHE. 

This bruises the gum, perhaps already irritated, and 
produces inflammation, great discomfort and pain. 
Here, sometimes, an incision, or sometimes better, 
a small excision, may give entire relief, and avoid all 
further trouble. But if the space between the jaws 
be too narrow ultimately to admit the protrusion of 
the full length of the crowns of these teeth, as there 
can be no attachment of the gum to the enamel of a 
tooth — enamel having no periosteum — a cul-de-sac, 
or pouch will be formed of a depth equal to the un- 
protruded portion of the crown. And if there be 
only room — as is by no means uncommon — for the 
protrusion of one or more of its cusps before meet- 
ing the opposing tooth, then this sac will be of a 
depth equal to the whole length of the crown. This 
sac forms a ready receptacle for food or any other 
matters taken into, or secreted by, the mouth, to lie 
in and decompose ; and this may produce inflamma- 
tion, ulceration, the burrowing of pus deep in the 
cellular tissue ; forming abscess, causing necrosis, 
exfoliations and all the other ills consequent upon 
severe inflammation. These more severe lesions, 
consequent upon the coming of the w T isdom teeth, 
so far at least as my observation goes, are confined 
to the lower jaw; and for the reasons, first, that I 



PATHOLOGY OF TOOTHACHE. 89 

believe the upper wisdom teeth are usually first in 
coming and are therefore the most fully protruded 
through the gum ; but chiefly for the reason that if 
food or other substances were forced, by mastication 
or otherwise, under the edge of the gum on the upper 
jaw, the force of gravitation would constantly tend 
to remove it, and would, generally, do so before it 
could do much harm ; whereas, in the lower jaw the 
same force would as constantly tend to keep it there. 

When the parts are in this condition, the only 
effectual remedy that I have ever found, or seen 
tried, is the removal of the teeth ; thus allowing the 
gums to contract, heal, and obliterate the sacs. 

I advise feelingly on this subject, having been 
obliged to have both my own lower wisdom teeth 
removed for this cause. 

A deposit of tartar upon the teeth often produces 
a low grade of inflammation of the gums and peri- 
dentinum, usually taking a chronic form. This 
sometimes produces a dull pain — pity it did not 
always produce acute pain and from its earliest 
stages— and, for the relief of this pain, we are some- 
times called upon to extract the teeth. The entire 
removal of the tartar, and proper local treatment, 
which should generally consist of a wash of some of 

8* 



90 PATHOLOGY OF TOOTHACHE. 

the stronger vegetable astringents, made stimulating 
by the addition of a little of some of the essential 
oils, or alcohol, and the frequent friction of a brush, 
and, if need be, in addition, some constitutional treat- 
ment, will generally effect a speedy relief and an 
effectual cure. Sometimes, however, especially on 
the lower teeth, the deposit, if long neglected, may 
have extended so near the point of the root as to 
render the entire removal of it impracticable, then 
extraction sometimes may, though very seldom, be 
required to afford relief. 

Sometimes when the teeth naturally stand slightly 
apart, or have been separated by the file or other- 
wise, food, while being masticated, may be forced 
through these spaces upon the gum with sufficient 
force to induce inflammation, and thus produce in- 
convenience and pain. The pain in such cases is 
generally not very severe, and, with a little care on 
the part of the patient, is not of very long duration. 
To extract a tooth for such a cause would, of course, 
be too great a sacrifice. 

From the foregoing remarks we may readily de- 
duce some pretty definite general rules to guide us 
in the extraction of teeth, or at least by which to 
determine pretty nearly what teeth require extrac- 
tion, and what ought not to be extracted. 



PATHOLOGY OF TOOTHACHE. 91 

1st. Any aching tooth, the crown of which is so 
far destroyed by caries that it cannot be restored to 
usefulness by being properly filled, should be ex- 
tracted ; unless the tooth be one of the upper in- 
cisors or cuspidati, the roots of which are often im- 
portant on which to engraft artificial crowns. In 
such cases great pains should be taken to preserve 
the roots and to restore them to health, irrespective 
of the state of their crowns. 

2d. Any tooth whose pulp is exposed, and either 
the tooth or the cavity in the tooth is so situated 
that it is impossible to get at and to thoroughly 
cleanse and fill its roots, as well as the cavity caused 
by the decay. 

3d. All aching teeth that have caused abscesses 
that have produced, or are producing, such lesions of 
the surrounding parts as to preclude a reasonable 
prospect of cure. 

4th. Such aching teeth as have exposed or in- 
flamed pulps, or incipient abscess, or have become 
painful from any other cause, and have already been 
rendered useless by the loss of thier antagonists in 
the opposing jaw. 

5th. All old roots of teeth that produce pain, 
from inflammation, or whose ragged edges are pro- 



92 PATHOLOGY OF TOOTHACHE. 

ducing inflammation in the surrounding gums or 
in any other way. 

6th. Wisdom teeth not having room between the 
jaws for their full development, and which from that 
cause, as before described, are producing inflamma- 
tion and pain. 

7th. All painful teeth unmistakably affected with 
exostosis. And besides these causes, 

8th. It is sometimes proper to remove even 
healthy and sound teeth : as where, for example, 
one has already lost most of his teeth, and those re- 
maining are useless by not standing opposite to each 
other ; or if there is only an occasional one left in 
the mouth, and the person wishes to be supplied with 
artificial substitutes, which by this means may be 
made much more serviceable than they can be with 
a few scattering natural teeth left remaining. But 
here, and in all other cases, too much care cannot 
well be used to avoid the removal of teeth that are 
useful, or that by suitable skill and care can be 
made so. 

But when any of the conditions exist in such force 
as to require the extraction of a tooth, I scarcely 
can conceive of any circumstance that would eon- 
traindicate the immediate performance of the opera- 



PATHOLOGY OF TOOTHACHE. 93 

tion, though some writers point out many such 
circumstances. A few of them we will examine. 

I have seen the following conditions set down as 
indicating the necessity of great care — by which I 
suppose is meant unusual care — in the operation of 
extraction, or of prior treatment, or of forbidding 
the extraction of the teeth altogether, to wit : 

."Extreme debility.'' 

" Great nervous irritability." 

" Excessive local inflammation, especially where it 
tends to the other parts." 

"Much irritability of the parts immediately con- 
nected with the teeth." 

"Pregnancy, and all uterine irritations."* 

Now to my mind, most, if not all of these con- 
ditions, instead of being causes for altogether re- 
fraining from extraction or of delaying that opera- 
tion, would be arguments cogent for the performance, 
and for the immediate performance of the operation. 

All possible care and gentleness should be used 
under all circumstances where extraction is required. 

Now, since there can hardly be a better established 
principle of surgery or medicine than that the 
readiest way to remove any disease is to remove its 

* Taft's Operative Dentistry, p. 342. 



94 PATHOLOGY OF TOOTHACHE. 

cause, I can scarcely conceive of a more sure cause 
of debility than the severe sufferings from toothache, 
and the loss of appetite, and sleep and rest occasion- 
ed by such suffering; therefore, if the pain could not 
otherwise be readily effectually palliated so as to give 
rest ancl comfort, and if the patient were not already 
moribund, I should regard debility, to almost any 
extent, an urgent cause for extraction, and that im- 
mediately, and should expect by it, not to increase, 
but to relieve the debility. And as I can scarcely 
conceive of anything more directly calculated to 
keep up and to increase "great nervous irritability, " 
or to excite and maintain " excessive local inflamma- 
tion," whether " it tends to the other parts" or not ; 
or to excite " much irritability of the parts intimately 
connected w T ith the teeth," than a diseased and aching 
tooth, if I saw any or all of these conditions accom- 
panying, I should consider each one an additional 
reason for the immediate extraction of the irritating 
cause. This would certainly be my general rule, 
though there might possibly, sometimes, be such ex- 
treme cases of irritation and debility as would require 
delay, for improvement in the general condition, lest 
the shock of the operation prove too severe for the 
enfeebled powers to endure ; but whenever such a 



PATHOLOGY OF TOOTHACHE. 95 

case occurs, great care must be taken u that the 
patient does not die in getting well." 

Of the expediency of extracting teeth, in ordinary 
cases, during pregnancy, there may perhaps be better 
grounds for different opinions. That there is a pretty 
strong sympathetic influence existing between the 
uterus and the teeth, and manifested most particu- 
larly when that organ is in the gravid state, there 
can be no doubt, as it is not uncommon when in that 
state, or when it is in an irritable condition from 
other causes, for it to produce strong sympathetic 
influences even on sound teeth, so as to occasion 
great discomfort, and to lead to the impression that 
they should be removed. Too much care, of course, 
cannot be observed to avoid falling into such mis- 
takes. But, although we admit the great sympathy 
between the teeth and uterus, and that any great 
violence to the teeth may make a very distinct im- 
pression there, and especially when in the gravid 
state, I cannot regard pregnancy as a valid objection 
to the extraction of aching teeth, the pain of which 
cannot otherwise be palliated. By theory, and by 
practice, I have ever maintained that the danger of 
abortion is greater from the constant pain and sym- 
pathetic irritation, and the debility consequent upon 



96 PATHOLOGY OF TOOTHACHE. 

the loss of rest and sleep, than by the operation ; 
and although I have extracted teeth for many women 
while in that condition, I have never yet known any 
untoward results to follow. Still, I can well con- 
ceive that in a feeble person, of great nervous irrita- 
bility, especially if she had previously been subject 
to abortions, the extraction of a tooth, and more 
particularly if the operation be roughly performed, 
might produce that result. Therefore, in such cases, 
it would be but prudent to try the effect of pallia- 
tives ; and if these afford a tolerable degree of com- 
fort, extraction is safer omitted ; but if these do not 
afford relief, it is but a choice between two evils of 
which extraction will generally be found the less, but 
circumstances may sometimes render it the greater ; 
of w^hich every judicious practitioner will necessarily 
judge for himself at the time. 



CHAPTER IV. 

INSTRUMENTS USED FOR EXTRACTING TEETH 
AND THE PROPER METHOD OF USING THEM. 

Sec. 1. Having now studied the anatomy of the 
teeth and jaws, and, from a consideration of the 
pathology of toothache, seen what teeth require ex- 
traction, we next come to consider the instruments 
used, and those most appropriate to be used, in the 
operation ; as well as the most proper methods of 
using them. They are of various kinds, and to be 
fully prepared to extract all classes of teeth, and 
under all conditions and circumstances, requires a 
considerable variety ; but there are some kinds of 
instruments, and in very general use, that ought 
entirely to be laid aside, and never more to be used ; 
and many instruments of a proper kind — or at least 
bearing the names of the proper kinds of instru- 
ments — are so badly constructed as to render them 
but little, if any, less objectionable. Some of these 
I shall describe, and the mode of their action, only 
9 



98 INSTRUMENTS FOR EXTRACTING TEETH. 

to caution all, and especially beginners, against 
their use. 

The instrument which is probably in more general 
use for the extraction of teeth than any other single 
instrument, and by the use of which more accidents 
and injuries are committed than by all other ex- 
tracting instruments combined, is the turnkey ; 
therefore from its great power to do evil, as well as 
its extensive use and antiquity, (having been in- 
vented, as it is said, near the beginning of the last 
century, or about one hundred and fifty years ago,) 
seems to require some notice. 

This instrument of torture, and of dread, consists 
of a steel shaft about five inches in length, and the 

Fig. 17. 




fourth of an inch in thickness, either straight or 
bent, much or little, and in various ways, the better 



INSTRUMENTS FOR EXTRACTING TEETH. 99 

to facilitate its application. On one end of this 
shaft is a horizontal projection or fulcrum, of vari- 
ous lengths, sizes and shapes, and either fixed to 
the shaft or attached to it by a kind of hinge, to 
suit the fancy of the maker or the operator. To 
this end of the shaft, too, is fixed a moveable hook 
or claw, with which to grasp the tooth. On the 
other end of the shaft is fixed a transverse handle, 
about three and a half inches long. 

When the instrument is applied, the fulcrum rests 
upon the gum and edge of the alveolar process on 
one side of the tooth to be operated on, while the 
hook or claw is placed in contact with its neck, on 
the other side. 

" This instrument may be regarded in the light 
of the wheel and axle; the hand of the operator 
acting on two spokes of the wheel, to move it, while 
the tooth is fixed to the axle by the claw." 

It is plain from this description, or from a glance 
at the instrument, and the situation of any tooth in 
the jaw, that the lowest point at which the claw can 
be brought in contact with, and take hold upon the 
tooth, can be but very little, if any, below the level 
of the bearing of the fulcrum on the opposite side ; 
and therefore the force applied to the tooth is not in 



100 INSTRUMENTS FOR EXTRACTING TEETH. 

the direction of the axis of the tooth and its socket ; 
but, even when best applied, under the necessities of 
the case, it must be diagonally across it; and, that, 
by this means that part of the tooth next to the 
fulcrum must impinge strongly on that side of the 
alveolar cell, while the end of the root, or roots, 
must as strongly impinge on the bottom of the cell 
at the opposite side, thus necessarily requiring a 
greatly unnecessary amount of force, by this indirect 
manner of applying it, as well as to overcome a large 
amount of friction occasioned by this indirect or 
lateral force. It is plain, too, in theory, and practice 
has a thousand times proved it, that if the tooth be 
an upper molar, with fangs much divergent, some or 
all of them must be broken, or the alveolus be 
wrenched away, before the tooth can be removed 
from its socket, by applying force in that direction. 

All this is on the supposition that the instrument 
is as well constructed and applied as it can be, with 
the point of the claw below the bearing of the ful- 
crum. But supposing that, by carelessness, inad- 
vertence or accident, the fulcrum is below or on a 
line with the point of the hook, then the only action 
of the force applied is across the tooth, and the only 
effect must be either to break it, or to split and 



INSTRUMENTS FOR EXTRACTING TEETH. 101 

wrench away the side of the alveolus, probably ac- 
companied with bruising and laceration of the gums ; 
all or either of which are unpleasant accidents. 

Another objection to this instrument not to be 
overlooked or ignored, is the liability, from the sud- 
den starting of the patient or from other causes, of 
the instrument to slip, even in careful hands, from 
the tooth to which it was applied, to the space 
between it and the tooth next in front of it, or even 
to the next tooth, thus taking out two teeth instead 
of one, or at least the wrong tooth ! — a serious and 
a mortifying accident that many a man has been 
subjected to, and by which many a patient has 
suffered. 

Much useless labor and thought has been expended 
in trying to invent a key, whose force should act in 
the line of the axis of the tooth to be removed ; but 
if it could be accomplished, the labor and the thought 
would still be useless, for the instrument when done 
would be altogether objectionable, and even wholly 
inadmissible, in practice ; for it must require a force 
in removing a tooth sufficient to rupture all the 
membranes at the same instant, and if its roots di- 
verge from each other, to break them or tear up the 
alveolar processes. 

9* 



102 INSTRUMENTS FOR EXTRACTING TEETH. 

The key, in any form, is a powerful instrument, 
but, at the best, a dangerous and a barbarous one. 

During the first ten years of my professional life, 
I used it often, and because I was so taught ; and 
although I never had any very serious accident occur 
from the use of it, in my hands, I never once in all 
that time took it in my hand, to extract a tooth, 
without feeling a degree of anxiety about the result. 

The Conical Screw is another instrument that has 
been long used for extracting certain teeth, and its 

Fig. 18. 




virtues much vaunted, which is of very little use ex- 
cept in theory. It is at most applicable for the 
removal of the roots of teeth in the upper jaw, and 
more particularly to those of the incisors and 
cuspidati. 

It is applied by inserting its point into the de- 
cayed, and thus enlarged canal of the root, and by 
a gentle force and a rotary motion causing it to cut 
a thread in the root, corresponding to the thread in 
the screw, and thus securing a hold by which to re- 
move it. 



INSTRUMENTS FOR EXTRACTING TEETH. 103 

The chief objections to this instrument arc, that 
it is but seldom that it can be made to cut a thread 
in the root of a tooth strong enough to answer the 
purpose intended; if the root is any ways long and 
firmly set, and if it be but short and frail, before a 
sufficient thread be cut by which to remove it, it will 
probably be split into fragments, and the operation 
thus complicated. And when it can be made to 
answer, especially if the root be sore, from inflam- 
mation, it will cause a great deal more pain than a 
more suitable instrument. And finally, it is — of no 
'practical account. 

A great deal of angry controversy was carried on, 
a few years ago, in some of the dental journals, as 
to who was entitled to the honor of inventing an in- 
strument, called a compound screw forceps, and com- 
bining the screw and the forceps. It consists of a 
pair of common straight forceps, with a conical screw, 
with its shaft inserted into a cylinder, which is, one 
end of it, let into the joint of the forceps, so that it 
can play between the blades like the clapper of a bell, 
and the screw so arranged by a spiral spring in the 
cylinder, that it can be thrust out from the blades 
somewhat like the tongue of a serpent, to be seized 
by the blades of the instrument, and screwed into 



104 INSTRUMENTS FOR EXTRACTING TEETH. 

the hollow root ; and then the b'ades opened, and 
made to grasp the outside of the same. 

Fig. 19. 





The operator, however, will generally find, in 
using this instrument, that after he has carefully in- 
serted the screw into the root, and carefully applied 
the blades upon it, and carefully made rotation and 
traction, he has very carefully brought away his 
whole instrument, and a small portion of the almost 
friable edges of the root, and nothing more, leaving 
the greater part, and the important part, of it in the 
jaw, to be removed by some more effective means. 

I once spent considerable time, labor, and pains, 
in describing, for the inventor, what I believe was 
the first instrument of this kind ever made ; but the 
instrument, when perfected, was never, to me, worth 
half the trouble it took to describe it. 



INSTRUMENTS FOR EXTRACTING TEETH. 105 

There are various hooks and punches, for removing 
roots of teeth ; and chisels for chipping away the 
alveolar processes, to enable the operator to grasp 
roots and broken teeth, and to facilitate their removal, 
which are often, if not most generally found in ex- 
tracting cases, all, or any of which may be made to 
answer the purpose for which they are intended, but 
are very ill adapted to the purpose, and ought to be 
regarded as only so much useless lumber. 

But to be fully prepared for all cases and emer- 
gencies that occur in extracting teeth, quite a variety 
of instruments are certainly needed, but if they are 
good, well made, properly constructed by being well 
fitted to the teeth on which they are intended to act, 
a smaller number will be much more efficient, and 
useful, than ever so many of bad quality, bad con- 
struction, and ill adaptation. 

But to be thus thoroughly prepared for all cases 
in both temporary and permanent sets, each extract- 
ing case should be supplied with at least fifteen pairs 
of forceps. And, although a smaller number may be 
made to answer, in all ordinary cases, circumstances 
arise, and cases occur, where even more than this 
will be found convenient. Of these there should be 
three pairs of straight forceps, designed chiefly for 



106 INSTRUMENTS FOR EXTRACTING TEETH. 

the upper incisors and cuspidati, one pair of upper 
bicuspid forceps , two pairs upper molar ; one pair 
lower incisors and cuspidati ; two pairs lower cuspi- 
dati, and one pair of lower molar forceps, a similar 
set of small molar, adapted to the size of the tempo- 
rary set, and one pair of quite small straight forceps 
for the incisors of the temporary set ; these will also 
be found useful for removing loosened roots or frag- 
ments of bone ; also one or two pairs for irregular 
teeth, and one pair of quite small root forceps for the, 
lower jaw. This last pair is perhaps the least essen- 
tial of any, but will often be found very convenient. 

Besides a good supply of forceps, each case should 
contain two elevators, and one gouge. 

All these instruments should be made of the best 
cast steel, and be of the most perfect spring temper, 
as this temper affords the greatest amount of strength 
with the same weight of metal, and an instrument 
that has a slight amount of elasticity not only breaks 
less easily, but takes something from the disagreeable 
shock produced by an entirely unyielding instrument, 
and is also, on that account, less liable to break the 
tooth to which it is applied. 

The first pair of straight forceps should be rather 
small, with delicate, evenly tapered, well tempered 



INSTRUMENTS FOR EXTRACTING TEETH. 107 

blades ; their points finished down to sharp cutting 
edges, and slightly rounded or gouge shaped, so that 
they can be readily and easily carried under the 
gum, cutting their own way quite to, or, if necessary, 
even beyond the edge of the alveolus. The general 

Fig. 20. 




form of the blades should be a segment of a somewhat 
conical cylinder ; and, as by a recurrence to the de- 
scription of the form of the roots of the single rooted 
teeth, it will be observed that the outer portion of 
the root is larger than the inner, it will readily be 
seen, that in order that the forceps should fit the 
root correctly, one blade of the forceps should be the 
segment of a somewhat larger cylinder than the 
other. They should be as wide as the tooth to which 
they are applied will admit, allowing sufficient space 
for a slight rotary motion, without bringing the sides 
of the instrument in contact with the adjoining 
teeth. The importance of this is evident, from the 
plain fact that an instrument so narrow, or with jaws 
so nearly plain on their inner surfaces, that where 



108 INSTRUMENTS FOR EXTRACTING TEETH. 

applied they would bear on two small portions only 
of a tooth, which is in fact a cylinder, would readily 
crush it ; whereas, if the same tooth or root was en- 
circled, to a considerable extent on two of its sides, 
it would bear almost any amount of force without 
being crushed ; and besides this, if an instrument so 
enclose a tooth, there is far less liability of its slip- 
ping in giving the necessary rotary motion to rupture 
the membranes that confine it to its socket, than if 
seized by a smaller surface. But as the same class 
of teeth in different individuals vary materially in 
size, and as the central and lateral incisors and the 
cuspidati, in the same individual always are of different 
sizes, it is obvious that no one instrument, nor any 
two or three instruments can thus accurately fit all 
the teeth to which they are to be applied ; but by 
carefully fitting one instrument to a tooth about the 
average, or a little above the average size, and 
another to one a little below that size, the tw T o can 
be made to answer, very well, in all ordinary cases. 
Their blades or jaws, should also be set so far 
apart at the joint, that when their ends have firmly 
grasped the neck of the tooth, they shall not impinge 
upon and crush their crowns ; nor in doing this, 
should the blades be much if at all curved, but they 



INSTRUMENTS FOR EXTRACTING TEETH. 109 

should rather approximate each other in direct lines 
from their joint to their points, otherwise they will 
act to some extent as excising forceps, and are there- 
fore liable to break the tooth, instead of extract- 



ing it. 



Fig. 21. 




The comparative length of the blades and handle 
of the instrument is also of some importance. If 
the blades are too short, in proportion, the leverage 
of the handles will be so great, that a sufficient 
amount of force to extract the tooth, will crush it ; 
and on the other hand, if the blades are too long, an 
extra amount of force beyond what is necessary to 
extract the tooth, will be required, by the grip of 
the hand, to prevent the instrument from slipping 
from the tooth, while, of course, the tractile force of 
10 



110 INSTRUMENTS FOR EXTRACTING TEETH. 

either instrument would be precisely the same, pro- 
vided the entire length of each of the two instruments 
was the same. Therefore, a proper medium should 
be observed in this regard. This principle holds in 
relation to all classes of forceps. What I would re- 
gard as about a fair proportion w r ould be, if the 
whole instrument were seven inches in length, the 
jaws should be about from one inch and three-eighths 
to one inch and a half, measuring from the centre of 
the rivet. 

This size of straight forceps are to be used gene- 
rally for extracting the smaller central and the 
lateral. 

The next pair should be of similar form and con- 
struction to those just described, but wider, heavier 
and stronger, and are to be used in the extraction of 
the cuspidati and some of the larger and more firmly 
set central incisors. 

The third pair should also be rather heavy and 
strong, though not necessarily quite as heavy as the 
last described. They are a kind of semi-cutting 
forceps, intended especially for the removal of the 
roots of the incisors, cuspidati and bicuspidati, when 
one has been so unfortunate as to break one of these 
teeth in attempting to extract it. This is commonly 



INSTRUMENTS FOR EXTRACTING TEETH. Ill 

known as the Parmly forceps, and is a most useful and 
almost indispensable instrument. The blades of these 
forceps are shaped very nearly like a carpenters "pod 
bit" or gimlet, with sharp cutting edges at their 
ends, and for about three eighths of an inch along 
their sides ; and are hollowed out on their approximal 
sides about as deep as the thickness of the alveolar 

FrG. 22. 




process, so that, when applied, they may fully cut 
through the process on each side, but without cutting 
the root of the tooth. 

Before applying this instrument, the gum should 
be slit along the course of the root to be removed, 
and dissected from the alveolar process, far enough 
to admit of its free and easy application. It is then 
applied over the process, on each side of the root, as 
far up as is deemed necessary, from an eighth to a 
fourth of an inch usually, when with one stroke of 
the forceps, the process on both sides is completely 
and smoothly cut through, and the root at the same 
moment firmly seized, which is then, of course, very 



112 INSTRUMENTS FOR EXTRACTING TEETH. 



easily removed, as its attachments are so nearly all 
cut away. 

There is no instrument that I have ever used 
with greater satisfaction than this. It does at one 
motion, smoothly, effectually and with greater ease 
to both patient and operator, all that can he done by 
tediously and roughly and painfully chipping away 
the alveolus with chisel and gouge and mallet, and 
after that the use of forceps, or punch, or turnkey, 
as is the habit of many. 

In selecting or having upper bicuspid forceps made, 
the same care should be observed in relation to their 
fitting the necks of the teeth on which they are in- 
tended to be used, and without touching their crowns. 
Nor should they bear upon the very end of the in- 
strument only, for if so, they do not hold the tooth 
firmly, and they act besides as a cutting forcep. 

Their blades should, also, like the straight forceps. 

Fig. 23. 




be cylindrical, so as to encircle as much of the tooth 
as is admissible, and the blade intended for the inner 



INSTRUMENTS FOR EXTRACTING TEETH. 113 

or lingual side of the tooth should be a little smaller 
than the other. The points of these forceps, too, 
should be sharp, so that they will pass readily under 
the gums cutting their way, and not bruising it. 
Many of the forceps of this kind that are offered for 
sale, are both too blunt and too much curved in their 
blades, so that they are bungling to apply, and when 
applied their bearing is too directly, too entirely on 
their very points, making them act either as cutting 
forceps or else allowing their handles to rotate on 
the points of the instrument, until the crown of the 
tooth impinges on one blade of the instrument, while 
the point of the other blade acts as a fulcrum over 
which to break off the tooth. Another common ob- 

Fig. 24. 




jection to this kind of forceps is that the blades are 
set at too great an angle to the handles, either for 
effectiveness or convenience. Indeed, forceps for 
these teeth made entirely straight, with the blades a 

10* 



114 INSTRUMENTS FOR EXTRACTING TEETH. 

little narrower, than the common incisor forceps, but 
enough thicker to give them their requisite strength, 
and set enough further apart at the joint to clear the 
greater thickness of the crowns of these teeth, is 
quite as convenient as any other form. And as the 
same instrument is equally adapted to each side of the 
mouth, if both handles are made alike, it is more conve- 
nient than if one is bent to fit around the little finger. 
Great care should also be taken that the upper 
molar forceps — which must be rights and lefts — are 
well adapted to the class of teeth on which they are 
to be used, as well as to the hand. Their general 
form is so well established and known that a definite 
description can hardly be deemed necessary, or any 
suggestions on that head further than, that they are 
generally made more crooked than is either neces- 
sary or convenient, and as each forcep is always used 
for its ow r n definite side of the mouth, they afford a 
firmer and securer hold for the hand if one handle is 
bent around the little finger, than if both are made 
straight. But as correct adaptation — accuracy of 
fit — of the instrument to the tooth, both for efficiency 
of action, and to avoid, as much as possible, the 
breaking of the teeth or other accidents, is a con- 
sideration of prime importance, I shall describe 
this part of it somewhat minutely. 



INSTRUMENTS FOR EXTRACTING TEETH. 



115 



As the upper molar teeth have, almost uniformly, 
three roots, two external and one internal, it is evi- 
dent that, to fit the tooth accurately, the blades of 
the instrument must be of entirely different forms. 
Thus ; the internal blade must be a single concave or 

Fig. 25. 




crescent shape, and of the width of the neck of a 
medium sized tooth of that class. The external 
blade, at its point, must be a double concave, with a 
point between, to fit into the bifurcation of the ex- 
ternal roots. But, as these external roots are of 
unequal sizes, the anterior being larger and also more 
prominent than the other, so the grooves or concavities 
in the blade of the instrument must be of different 



116 INSTRUMENTS FOR EXTRACTING TEETH. 

sizes to fit them ; the anterior groove being both 
larger and deeper than the posterior, otherwise the 
bearing of this blade will be only on the anterior 
root, and the point, intended for that purpose, cannot 
reach the bifurcation of the roots ; the result of which 
would be that the instrument is liable to slip alto- 
gether from the tooth or to glance off against the 
posterior tooth, endangering it ; and even if it do not 
slip it is more liable to break the tooth than if it 
fitted it accurately. The relative difference in the 
size of these grooves should be about as three to two; 
that is, the anterior groove should be about three- 
fifths, and the posterior about two fifths of the width 
of the instrument; and the anterior should be nearly 
or quite twice the depth of the other. The point 
should be distinct and prominent; thick enough to 
give it strength, and turned slightly inwards so that 
when once fairly applied to the bifurcation of the 
roots, there can be no possibility of its slipping ; or 
so that if necessary, as frequently happens, when the 
crown of the tooth has been broken off, it can be 
placed over the alveolus, piercing through it and 
taking hold in the bifurcation of the roots. 

The first and second upper molars are so nearly alike 
that an instrument well adapted to one will answer 



INSTRUMENTS FOR EXTRACTING TEETH. 117 



equally well for the other. The roots of the upper 
wisdom teeth are so frequently close together or all 
condensed into one, and as they do FlG 26 
not usually require much force to re- 
move them, an instrument with a less 
prominent central point, or even one, 
both blades of which are a single con- 
cave, will often answer better. 

For the removal of the lower teeth, 
and their roots, as already intimated, 
four or at most five pairs of forceps 
are all that are necessary. One pair g 
for the incisors and cuspidati; one for g> 

o 

the bicuspidati, one for the removal ^ 
of the roots of the teeth when it is J 
necessary to remove a portion of the 
alveolus to get at them, and one pair 
for the first and second molars on both 
sides. Some, and perhaps most, ope- 
rators use two nairs for the lower 

JL 

molars, rights and lefts, but one only 
is better. A small pair of lower root 
forceps, w T ith very small blades, and 
the points of which come close together, will some- 
times be found very convenient for picking away 



118 INSTRUMENTS FOR EXTRACTING TEETH. 

loosened roots, or fragments of the alveolus, or frag- 
ments of teeth that may have been crushed in 
attempting to extract them ; but although sometimes 
very convenient, they are not very essential. 

The only difference required between the forceps 
for extracting the lower incisors and the lower bicus- 
pidati is, that those for the incisors should be narrower 
in their blades than the others. Those made by 
Toland and Chevalier and some other makers, are 
tolerably well adapted to the purpose ; though I like 
them better more bent in their joints than they are 
usually made, as then when applied it brings their 
handles, and of course the hand, further from the 
patient's face. I have mine represent an angle of 
something more than forty-five degrees. 

Fig. 21. 




The pair for the removal of the roots of such bi- 
cuspidati, or indeed of any other of the single rooted 
lower teeth, the crowns of which have been broken 
off in attempting to extract, and are so firmly set, or 
broken so far below the edge of the alveolus as to 



INSTRUMENTS FOR EXTRACTING TEETH. 119 

render it impossible, or inconvenient to remove 
them with the elevator ; or even the roots of the 
lower molars if broken below their bifurcation, was 
invented by mj^self in 1858. Their general form 
is the same as my ordinary lower bicuspid forceps, 
but having the pod-bit or gimlet-shaped blades, 
described for cutting the alveolar processes, and 
removing the roots, of such broken upper teeth; 
and is used in the same manner as that instrument, 
Fig. 28. 




t. e., by first dissecting away the gum, and enclosing 
a sufficient amount of both the processes and the 
root, within the jaws of the forceps; then cutting the 
process and removing the root at a single stroke ; 
which is effected so easily as often to surprise both 
patient and operator. I find this, now, an indispen- 
sable instrument, and can hardly understand how I 
got on so long without it ; and am sure that no one 
who had once used it, would consent to be with- 
out it. 

The lower molar forceps, which are generally 
offered for sale, unlike those for the upper molars, 



120 INSTRUMENTS FOR EXTRACTING TEETH. 

which are generally too crooked for effectiveness or 
convenience, are usually too straight. Their beaks 
should be bent downwards, one blade above the other, 
at an angle of at least forty-five degrees from the 
line of their handles. They should have a bend at 
or just in front of the joint, so that when applied it 
shall throw the handles to the front of the mouth ; 
they should then have another bend to bring the 
handles back nearly on a line parallel with the blades, 
for the nearer the handles and blades are to being on 
a line parallel to each other, so much the more 
directly will the force applied to the handles act on 
the object grasped by the blades. 

The ends of the blades should each be formed into 
two grooves, or a double concave, to fit them accu- 
rately to the necks of these double-rooted teeth, and 
with a centre point to enter the bifurcation ; and 
these centre points should be made longer, more 
hooked, and more pointed than they are usually 
made, or than I have ever found them at any of the 
" dental depots,''— a full fourth of an inch from the 
outside of the groove being quite short enough. The 
anterior roots of the lower molar teeth being larger 
and more prominent than the posterior, these 
grooves of a width and depth to correspond, i. e., 



INSTRUMENTS FOR EXTRACTING TEETH. 



121 



the anterior should be deeper and wider than the 
posterior. Forceps thus made, when fairly applied, 
seize the tooth firmly ; there is no danger of their 
slipping, and very little danger of ever breaking a 
tooth in attempting to extract. 

With an instrument thus shaped, the mere act of 
applying it is often sufficient to remove the tooth, 
for these long tapering points having fairly entered 

Fig. 29. 




the bifurcation, the upper side of each point as it is 
further forced in, bears hard upward on the tooth, 
while the other bears as hard upon the edge of the 
alveolus, thus acting like two little wedges, and with 
11 



122 INSTRUMENTS FOR EXTRACTING TEETH. 

sufficient force to raise the tooth from its socket, 
by simply closing the instrument upon the tooth. 

Another great advantage of this form of beak is, 
that when the crown of a tooth has been broken off 
above the bifurcation, that is, without separating its 
roots, the gum can be dissected from the alveolus for 
a short distance, and the instrument applied in the 
line of the bifurcation, and low enough down to 
secure its points entering there, when with but a 
slight force upon its handles, the beaks will pierce 
the alveolus, firmly seizing the roots, when they may 
be easily and securely removed, and without any 
chipping or hacking of the alveolus ; and in less time 
than it takes to describe the operation. 

These forceps, like all others, should have their 
blades wide enough apart, that, when firmly applied, 
the crown of the tooth shall be perfectly free, other- 
wise it will very likely be crushed or broken. 

I will here remark, en passant, that when only one 
pair of forceps is used for the teeth on both sides of 
the lower jaw — and it is much more convenient and 
effective than rights and lefts — it should be the one 
made for the right side. 

Besides the forceps already described, it will some- 
times be found very convenient, for every one who 



INSTRUMENTS FOR EXTRACTING TEETH. 123 

extracts many teeth, to have one or two pairs with 
very narrow, but, at the same time, very strong 
blades for extracting irregular teeth. Several very 
good patterns of this kind can be found in most of 
the principal dental depots. 

The forceps for extracting the deciduous teeth 
should have the same forms as the corresponding in- 
struments for adult teeth, but of only about half 
their size. And such a set, consisting of about three 
instruments — that is for the molars, are verv neces- 
sary. But I cannot refrain from remarking here, 
that these instruments should be used very sparingly, 
great harm is done by the indiscriminate extraction 
of children's teeth. 

Of the elevators, one should be the common 
straight, spear-shape headed elevator of the depots, 
modified and greatly improved by having its head 
about one third smaller than they are usually made, 

Fig. 30. 
Front view. 




Side view. 



or to be more particular in its description, it should 
be, in its entire length, about five and a half inches, 



124 INSTRUMENTS FOR EXTRACTING TEETH. 

The handle, the foundation of which should be a flat- 
tened continuation of the shaft, covered on each side 
with ivory, ebony, hardened rubber or other suitable 
material, should be about three and a half inches in 
length, by about a half an inch in width. The shaft 
should be gracefully tapered from the handle to the 
head, and about an inch and three-fourths in length. 
The head should be about one-fourth of an inch, or 
a little more in length, and a fourth of an inch, or a 
little less in its greatest width, and tapered to a 
point. One side of the head should be flat or very 
slightly concave, and the other side oval, and at its 
thickest part it should be nearly an eighth of an inch 
thick. The head of the instrument, regarding the 
flat surface as the front, should be bent backward, at 
an angle of fifteen or twenty degrees from the line 
of the shaft. This greatly facilitates its application, 
and adds much to its power. 

This instrument is sometimes very useful in ex- 
tracting roots of teeth, but more especially for ex- 
tracting the lower wisdom teeth. But, of its use, I 
shall speak more fully when treating of the extraction 
of the wisdom teeth. 

The other elevator should be about five inches or 
a little less in length, including its handle, which 



INSTRUMENTS FOR EXTRACTING TEETH. 125 

should be about half the whole length of the instru- 
ment, round and well fitted to the hand. Its blade 

FiCx. 31. 




should be about half an inch in length, and set at an 
angle of full forty-five degrees from the line of its 
shaft. Its form and size should be that of the same 
length cut from one blade of a medium sized common 
straight pair of forceps, the concave side front ; its 
point sharp, and slightly rounded, or gouge-shaped. 

This instrument is used chiefly in the extraction of 
the roots of teeth, and is applied by placing the con- 
cave side of its point against the root to be removed, 
carrying it down perpendicularly, as far as practi- 
cable, between the root and its alveolus, then de- 
pressing the handle, thus using the edge of that 
process to some extent, as a fulcrum over which to 
pry out the root ; or else with an upward (if in the 
lower jaw, downward if in the upper,) motion, push 
or force the root from its socket. 

This elevator is applicable to the roots of all 
classes of teeth, and is more serviceable in extracting 
roots than any other single instrument, or perhaps 

11* 



126 INSTRUMENTS FOR EXTRACTING TEETH. 

than all other instruments combined ; and especially 
if they be very badly decayed and frail roots. Its 
sharp, rounded point, can readily be thrust some 
distance between the root of almost any tooth and its 
alveolus, at the same time rupturing, to some extent 
on one side at least, its articulating membrane, peri- 
osteum or peridenteum, as it is sometimes called ; and 
securing a good hold on the root, without danger of 
breaking or crushing it, with much less pain to the 
patient than the application of forceps, as it comes 
in contact with but one side of the root, and very 
rarely requires any lancing of the gum ; all material 
advantages, both in its application and use, over 
either the forceps, or the elevators with serrated or 
bifurcated points as they are most generally made. 
The gouge, of the extracting case, should be, in- 

Fig. 32. 



eluding its handle, about six inches in length, three- 
sixteenths of an inch in width, and shaped like the 
Turner s gouge. 

This is used for the removal of the roots of the 
teeth that are decayed or broken off, so high up in 
their sockets as to be beyond the reach of the ele- 



INSTRUMENTS FOR EXTRACTING TEETH. 127 

vator. It is generally applicable only to the upper 
jaw. It is applied by passing it up the cell of the 
alveolus, until it reaches the root, and then carefully 
inserting its edge between it and the parietes of its 
cell, when with a gentle pressure, and a rotary 
motion of the instrument, the fragment of root is 
at once and easily removed with very little trouble 
to the operator, and usually w T ith but comparatively 
little pain to the patient. 

In this manner I have removed the point of a 
canine tooth, not more than three-sixteenths of an 
inch in length, and broken off full three eighths of 
an inch above the edge of the alveolus, where, no 
other instrument could possibly reach it, without first 
cutting away at least, half an inch from the alveolus ; 
and, of course, involving a pretty severe wound in 
the contiguous soft parts. 

This is truly a very valuable little instrument ; and 
no extracting case should be considered fully equipped 
without it. 

Having described the necessary, and, as I think, 
the most appropriate the best instruments for ex- 
tracting all classes of teeth, and roots of teeth, in 
the easiest and best possible manner ; that is, for 
removing every portion of a tooth, whether whole or 



128 INSTRUMENTS FOR EXTRACTING TEETH. 

in fragments, with the greatest facility to the opera- 
tor, and with the least pain, or other injury to the 
patient, we now come to a consideration of the mode 
of using them so as most effectually to attain these 
objects. 

Sec. 11. Mariner of using Instruments. 

But as a preliminary to that, I will remark, that 
proper success in extracting teeth depends very much 
on the manner of the operator. He should, first of 
all, not only seem to be, but be calm and self- 
possessed ; and this state is to be attained in two 
ways ; either by the ignorant recklessness of the 
charlatan, which cannot be too severely reprehended ; 
or by the confidence inspired bj? a definite knowledge 
of the parts to be operated on, and which is to be 
acquired only by study, observation and experience. 
Calmness and self-possession in the operator, is the 
readiest and most effectual means of securing the 
confidence of the patient ; and that especially in all 
difficult cases, and with nervous, excitable patients — 
and most patients are apt to be a little nervous when 
about to have a tooth extracted — and with children, 
is a very important circumstance. 

A patient that is excited, or that lacks confidence 



INSTRUMENTS FOR EXTRACTING TEETH. 129 

in the operator, is far more likely to be restless, to 
start suddenly, to jerk about the head, to throw up 
the hands, and seize those of the operator, and thus 
break off teeth that otherwise need not, and would 
not be broken, if calm and confident. 

Undue anxiety to operate, and to do it quickly, or 
apparent timidity, or want of confidence in his own 
skill and ability excite suspicion, and want of confi- 
dence on the part of the patient ; while, on the other 
hand, a boisterous, blustering, self assurance may 
excite disgust ; all of which operate sadly against the 
success, and the reputation of the operator. 

I cannot here refrain from a few remarks on the 
treatment proper to be used toward children when 
about to be subjected to the operation of having a 
tooth extracted. 

It is common, far too common, under such circum- 
stances, for both operators and friends and even 
parents, to deceive children by telling them it will 
not hurt them to have their teeth extracted, or to 
tell them to " open their mouths so that the doctor 
can look at it, and that he is not going to do any- 
thing to it, or that he will not touch it, or that he 
will just put something on it, to make it well," and 
the like ; intended only to gain the confidence of the 



130 INSTRUMENTS FOR EXTRACTING TEETH. 

child, and then, covertly apply the forceps, and ex- 
tract the tooth before it has time to resist ; thus 
betraying that confidence and deceiving the child ! 
Sooner, by far, would I hold a child by force, and 
extract its tooth, than thus demoralize it, by teaching 
it such a lesson of untruthfulness, and so shaking its 
confidence in the integrity of its friends and of man- 
kind. For myself I never allow any one thus to de- 
ceive a child in my presence, on whom. I am about 
to operate, without the rebuke, at least, of at once 
correcting the impression ; and much less would I 
ever allow myself to commit such an act. Children 
reason as well as others, and if plainly and honestly 
told that the operation will hurt, but that it will 
probably hurt less than is anticipated, and that it is 
better even to endure severer pain for a moment, and 
be done with it, than to suffer for an indefinite time, 
and then be hurt quite as badly, and perhaps worse, 
than now, in having it out. Such persuasions, with 
kindness, will usually secure the consent of the little 
sufferer, and retain his confidence and respect ; but, 
as already remarked, if reasoning and persuasion 
fail, it is far better to use force than deception. 

I will here further premise, that no one ought 
ever to attempt to extract any tooth, without first 



INSTRUMENTS FOR EXTRACTING TEETH. 131 

making a careful, preliminary, examination of the 
case. First to satisfy himself whether the tooth 
ought to be extracted. 

Patients suffering from toothache are very often 
deceived in relation to the tooth that causes the pain ; 
and then to extract the one that they might indicate 
without such examination, would be committing a 
great fault, and an irreparable injury to the patient. 
Woful mistakes are, in this way, frequently com- 
mitted, for which there can be no justification. 
Patients often fancy, too, since artificial teeth have 
become so fashionable, that they ought to have even 
useful teeth taken out, and artificial ones inserted in 
their stead. This mistake ought not to be made, or 
at the least, judicious advice should always be given 
in all such cases. 

Secondly, after being satisfied o£ the necessity of 
the operation, the tooth to be extracted should be 
carefully examined in regard to its strength, its 
position, the firmness of its attachments, and the 
probable force that will be required for its removal ; 
the instrument or instruments most appropriate to 
be used ; and the best manner of using them. 

These preliminaries having been gone through 
with, the patient being seated in a slightly reclining 



132 INSTRUMENTS FOR EXTRACTING TEETH. 

position — suppose the tooth requiring extraction to 
be a superior central incisor, the common straight 
forceps, of the size and strength suited to the size 
and strength of the tooth, should be taken, (no more 
instruments ever being displayed than are necessary 
for the proper performance of the operation in hand) ; 
then standing on the right side, and slightly in ad- 
vance of the patient ; the left arm closely surrounding 
the patient's head, thus giving it a firm support ; the 
palm of the left hand resting on the patient's left 
cheek, and the fingers opening and protecting the 
lips ; apply the blades of the forceps over the tooth, 
with their points at the edge of the gum ; close them 
lightly upon the tooth, and then carry them up firmly 
and decidedly, till their progress is stopped by the 
edge of the alveolar process ; then close them firmly 
upon the neck of the tooth, and give one or two 
rotary motions, back and forth, sufficient in force 
and extent to sever the periosteum, when a slight 
tractile force will be sufficient to remove the tooth. 
As the roots of these teeth are nearly, and sometimes 
quite round, the rotary motion ruptures their articu- 
lating membranes more readily than any other. 

I will here remark, once for all, that all efforts at 
extracting this or any other class of teeth, should he 



INSTRUMENTS FOR EXTRACTING TEETH. 133 

made firmly and deliberately . All quick or jerking 
motions produce unnecessary shock and alarm to the 
patient, and greatly endanger the breaking of the 
teeth ; especially if they are badly decayed and frail. 
A good rule in this regard is, never to move the 
hand faster than its effects can be followed and ap- 
preciated by the eye, so that it can at once be 
stayed, if it is perceived that undue injury is being 
inflicted, on any of the contiguous parts. "An 
operation is generally soon enough performed, that 
is well performed. , ' 

For extracting the upper lateral incisors, and in- 
deed for all other teeth in the upper jaw, as well as 
all the teeth in the lower jaw, when forceps are used, 
except the incisors, cuspidatus, and bicuspidati on 
the left side of the lower jaw, the relative position of 
operator and patient should be essentially the same 
as for the extraction of the upper central incisors. 
The same forceps should generally be used, for the 
lateral as for the central incisors, but selected with 
reference to their adaptation to the width of the 
tooth ; and they should be applied in the same man- 
ner ; but as the roots of these teeth are generally 
more or less flattened on their " approximal" sides, 
a motion forward and backward will frequently, if 
12 



134 INSTRUMENTS FOR EXTRACTING TEETH. 

not generally, succeed better in severing their attach- 
ments than the rotary. 

•The cuspidati, for their removal, require the use 
of the strongest straight forceps ; which are to be ap- 
plied in the manner already described ; but as the 
roots of these teeth vary very much in their forms, 
sometimes being quite round, and sometimes very 
much flattened, and as they are also frequently much 
curved, or even crooked, producing the effect, so far 
as the motions for extraction are concerned, of very 
broad roots, the appropriate motions, whether rotary 
or forward and backward, must depend on these cir- 
cumstances, and can generally be determined by a 
careful examination. But when an examination does 
not determine their form, it must be decided by trial ; 
and in such cases it is perhaps best, usually to try 
the rotary motion first, and if that does not succeed, 
by a reasonable amount of force, then to try the 
other. 

The roots of these teeth usually being both larger 
and longer than those of the incisors, it generally 
requires more force to remove them. 

For extracting the upper bicuspidati, the forceps 
described as suited to those teeth should be taken, 
and placed upon the tooth, whether it be in the right 



INSTRUMENTS FOR EXTRACTING TEETH. 135 

or left side of the mouth, with the longest blade of 
the instrument on the palate side of the tooth, and 
carried well up, quite to the alveolus ; and the motions 
should be very firm, steady and gradual, first to and 
from the operator, in the direction across the mouth, 
and, when the attachments are severed, a tractile 
force sufficient to remove it from its socket. These 
teeth, and especially without this care, are more liable 
to be broken, in attempting to extract them, than 
any other class, and more particularly the anterior 
one, which is so frequently divided into two slender 
roots, which makes its attachments stronger, in pro- 
portion to the strength of the tooth, than any other. 
But one other great reason, and probably the most 
common one, for their being so frequently broken, 
is, that the forceps generally in use for extracting 
these teeth are both too stiff and too much curved, 
in their blades, so that they do not yield, in the least, 
to the force applied to them, thus bringing all the 
power too suddenly upon the tooth, and also to bear 
too entirely upon their points, like cutting forceps, 
or the point of one of the blades acting as a fulcrum 
over which to break off the tooth by the handles being 
allowed to rotate upon it till the opposite blade 
comes in contact with the crown of the tooth, as 
noted in the description of this kind of forceps. 



136 INSTRUMENTS FOR EXTRACTING TEETH. 

In extracting the upper molars, and particularly 
the first and second, as they have each three roots — 
two external and one internal — two pairs of forceps 
are required, one pair for each side of the mouth; 
the blades of which should be well fitted to the pecu- 
liar form of this class of teeth, as already described. 
They should be applied, like that for the bicuspidati, 
with the longest blade — the one having the single con- 
cave on the inner or palate side of the tooth. This 
blade should be forced firmly to the edge of the alveolar 
process, and the central point of the outer, or double 
concave blade should be forced under the edge of 
the process, so that it shall fairly enter the bifurca- 
tion of the external roots of the tooth, and the edges 
of the concavities shall be in apposition with the edge 
of the process. The motions should then be forward 
and backward, to rupture, the membranes, and then 
Fig. 33. 




tractile. These teeth being large and so firmly planted, 
require often a very considerable force for their re- 
moval ; but with such an instrument so applied there 



INSTRUMENTS FOR EXTRACTING TEETH. 137 

will be no danger of its slipping, or but very little 
danger of breaking the tooth, or of failure of success. 
For the wisdom teeth in this jaw, the forceps 
should be applied, as nearly as may be, in the same 
manner, and with great care; but, from the size of 
these teeth, a smaller pair of forceps than the com- 
mon molar usually answer best, (I generally use 
my children's forceps for these teeth.) As the roots 
of these teeth are generally close together, and fre- 
quently all united, a small pair of forceps, of the 
same general form as the ordinary molar forceps, 
but having each blade with only a single concave, in 
a majority of cases would be a better instrument.* 
When these teeth are curved, as they most commonly 
are, more or less— the face of the crown and the apex 
of the root both looking toward the cheek — the mo- 
tion and force required are mostly, if not entirely, 
from within, or from the palatine side of the tooth 
outward. The force necessary for their removal is 
generally much less than for the preceding, or, in= 
deed, than for any of the other teeth. 

* I have been latterly using Robert's upper wisdom tooth forceps. 
At first sight they seem to be a queer, crooked, awkward kind of in- 
strument; such was my first impression of them ; but on trial I have 
found them most admirably adapted to the purpose for which they 
are intended. 

12* 



138 INSTRUMENTS FOR EXTRACTING TEETH. 

The elevator is sometimes used for removing these 
teeth, and they can generally be very readily re- 
moved by it, but in so doing there is great danger of 
fracturing the pterygoid process of the sphenoid bone. 
Therefore the use of the elevator cannot be recom- 
mended for the extraction of these teeth. 

In extracting most of the teeth from the lower 
jaw, as already remarked, the position of the parties 
should be essentially the same as before described, but 
with these modifications : Instead of the palm of the 
operator's left hand resting on his patient's left cheek, 
the palm and last three fingers should firmly grasp 
the patient's chin, while the forefinger and thumb are 
to be used to remove and protect the lips and tongue. 
It will also be more convenient for the operator to be 
relatively more elevated, in relation to his patient in 
operating on this jaw than on the upper, especially 
in extracting the molar teeth, as he will thus be in a 
position to exert more force, and to do it more directly. 
And for this purpose a small movable platform, or 
stool, of about six inches in height, will be found very 
convenient. 

Having assumed the proper position, if it be either 
of the incisors, the cuspidatus or the bicuspidati that 
is to be extracted, take the instrument already de- 



INSTRUMENTS FOR EXTRACTING TEETH. 189 

scribed as suited to these teeth, place it upon the tooth 
with its longest, or upper blade on its inner, or lingual 
side, force both blades down firmly upon the edges 
of the alveolar process, and then with an inward and 
outward and an upward motion the tooth is usually 
readily removed. 

In extracting the lower molar teeth from the right 
side of the mouth, the longer or upper blade of the 
forceps (lower molar forceps) should be placed on 
the side of the tooth next to the tongue, care being 
used so to place them, and to force them down, that 
when closed their points shall fairly enter the bifur- 
cation of the roots of the tooth ; then with a firm, 
steady motion forward and backward, across the 
mouth, and proper tractile force, the tooth is usually 
with certainty removed. Sometimes, from the na- 

Fig. 34. 




ture of the case, this class of teeth require a great 
deal of force for their removal, as where the roots at 
first diverge considerably, and afterward converge, 



140 INSTRUMENTS FOR EXTRACTING TEETH, 

till their points come in contact, enclosing, as they 
must, an amount of the alveolus, which acts, to all 
intents, like a rivet to hold the tooth in its socket, 
and which must necessarily be broken and brought 
away between the roots, or one or both of the roots 
must be broken. So, too, when the roots of such a 
tooth diverge in their whole length, till they are 
wider across their points than at the neck ; they not 
only require a great deal of force to start them from 
their sockets, but it must frequently be continued till 
their very points have left them. In such cases the 
roots must spring enough to clear them, or one of 
them must break. Such an accident, in such a case, 
is unavoidable, and should bring no reproach upon 
the operator. 

In extracting the lower molars from the left side 
of the mouth, the same instrument is used as for 
those on the right side, but the shorter or lower blade 
must then be placed on the inner side of the tooth, 
which necessarily brings a large portion of the instru^ 
ment within the mouth. After it is applied, so that 
the points of the forceps fairly enter the bifurcation 
of the roots, the force is to be applied in the same 
manner as on the other side. The great advantages 
of using but one pair of forceps, for both sides of the 



INSTRUMENTS FOB EXTRACTING TEETH. 141 

mouth, in extracting these teeth are, that by stand- 
ing on the right side of his patient, the operator is 
in a much more favorable position to exert the ne- 
cessary force ; and he has also the full control of his 
patient's head, which he holds firmly and steadily by 
encircling it with his left arm, which he cannot do if 
he stands in front of his patient, as he is obliged to 
do if he uses the right and left hand forceps. 

In extracting the incisors or cuspidatus, and bicus- 
pidati of the left side of the lower jaw, it becomes 
necessary to stand as near directly in front of the 
patient as may be ; the chin of the patient grasped 
firmly with the operator's left hand, the fingers all 
being under the chin, while the thumb is within the 
mouth, and resting on the patient's other teeth. The 
instrument is then to be applied, and the force 
exerted in the same manner as in extraction of the 
teeth on the other side ; that is to say, the blades 
must first be carried quite to the alveolus, and the 
movements of the instrument inward and outward. 

The roots of all the lower teeth are so much com- 
pressed or flattened laterally, that they do not admit 
of the rotary motion for their removal ; neither does 
the form of a suitable instrument readily admit of 
that kind of motion. 



142 INSTRUMENTS FOR EXTRACTING TEETH. 

It will be observed that in my directions for the 
application of forceps, I have frequently repeated 
that they should be carried quite to, or even under 
the edge of the alveolar process. This I have done 
of design. I wish to impress the direction emphati- 
cally; for where a tooth is seized by its crown, or 
just at the base of the crown, instead of at its neck, 
it is almost sure to be broken, and not extracted. 
This should ever be borne in mind, and never for- 
gotten, whenever forceps are used, or in fact any 
other instrument. 

The wisdom teeth in the lower jaw are almost, if 
not quite, without exception, more or less curved or 
hook-shaped, thus forming nearly the segment of a 
circle, larger or smaller ; or sometimes the root stands 
at an angle little if any less than a right angle to its 
crown, and its apex or foramen always looking back- 
ward, or toward the ramus of the jaw. The crown 
of the tooth is short, and its neck very short. The 
tooth being in the posterior part of the mouth, the 
space between the jaws is frequently so small that it 
is difficult on that account fairly to grasp it with the 
forceps, which difficulty is also increased by its being 
so far from the front of the mouth ; and if grasped, 
from its position, it is difficult to bring the handles 



INSTRUMENTS FOR EXTRACTING TEETH. 143 

of the forceps into such a position as to act upon the 
tooth with any force without injuring the mouth with 
• them. The jaw is here wide and flat on its top, with 
almost no alveolar process, so that the points of the 
forceps can but rarely, if ever, be inserted into the 
bifurcation of the roots of the tooth, — if indeed the 
roots are bifurcated, and in a very large share of 
them they are not, — but can at most only seize the 
tooth on the two sharp points of the instrument, (if 
the common forceps are used, and with any forceps,) 
just at the base of its crown, where but a slight force 
is sure to break it off without removing its roots. It 
will readily be perceived by examination, that the 
shape and position of these teeth is such, that if the 
forceps could be ever so well applied, it would be 
almost impossible with them to exert a force in the 
directions necessary to remove them easily ; that is, 
in the direction of the axis of the tooth, as from 
their being placed so far back in the mouth, the force 
of the forceps must almost necessarily be forward 
and outward or sidewise, one w T hich must make the 
crown of the tooth operated on only impinge the 
more strongly against the crown of the second molar, 
(if that tooth is still in its place,) and the curved or 
hooked root incline to burst up the bone behind and 



144 INSTRUMENTS FOR EXTRACTING TEETH. 

above it, or if that be too strong to yield, to break 
the tooth ; whereas the force should be, readily to 
affect the object desired, directly upward and back- 
ivard. I, therefore, in removing this class of teeth, 
if the second molar is still in its place, always use 
the straight elevator (modified as described) by in- 
serting its point firmly between the neck of the 
tooth to be removed and that of the second molar, 
using that and the alveolus as a fulcrum over which 
to pry out the tooth. This, it is plain to see, exerts 
a force in the exact direction most directly to over- 
come all resistance ; or in other words, in that direc- 
tion that meets the least resistance, and that requires 
the least possible force to effect its removal. 

With this instrument, too, a lower wisdom tooth 
can quite readily be removed, when from abscess or 
other cause, the face is swelled, and the jaws closed 
to any extent short of absolute occlusion ; and I know 
of no other instrument that will effect the same result 
under such circumstances. 

The position to be assumed when using this instru- 
ment, for extracting these teeth on the left side, 
should be the same as in using the forceps in extract- 
ting the left lower incisors. On the right side, the 
same as for using the forceps on that side. 

If the second molar has already been removed, the 



INSTRUMENTS FOR EXTRACTING TEETH. 145 

straight elevator cannot be used, there being nothing 
left for a fulcrum over which to use it. But in such 
cases the other kind of elevator may sometimes be 
used with good effect, treating the tooth as if it were 
simply a root. The forceps, too, can better be ap- 
plied and used now, than when the second molar was 
in its place. But the means must be adapted to the 
emergencies of the case. 

As, in describing our instruments and the purposes 
to which they are applied, we have already, almost 
necessarily, described the method of extracting the 
roots of teeth whose crowns are gone, and as we shall 
have need to refer to that subject again to some ex- 
tent when treating of the accidents which are liable 
to occur in the operation of extraction, nothing fur- 
ther need be here said on the subject. 

With the necessary anatomical knowledge, and 
sufficient experience to acquire self-confidence ; with 
the instruments here described, and those instru- 
ments used as here directed, but little difficulty need 
ever be apprehended in the extraction of almost any 
tooth. True, some extraordinary cases will require 
extraordinary means, for which the operator must, to 
a great extent, rely on his own judgment, guided by 
the exigencies of the case. 



CHAPTER V. 
OF LANCING THE GUMS. 

The " Lancing the Gurus" in some cases of ex- 
traction, is a very important preliminary operation, 
and, when required, it should be done well and 
thoroughly. 

A description of the manner of doing it has already 
been incidentally given, when explaining the method 
of extracting the teeth, or rather, the crownless roots 
of teeth which require it ; to wit, the roots of such 
teeth as are broken off so far below the gum and the 
edge of the alveolus that they cannot be seized or 
apprehended by the instrument to be used for its 
removal, without either cutting or injuring the gum ; 
or such roots of teeth as from inflammation or other- 
wise, have the surrounding gums more or less closed 
over them, rendering it difficult to apply any instru- 
ment without first removing the gum, or at least not 
without inflicting a great deal more pain, with the 
extracting instrument than with the knife. The 



LANCING THE GUMS. 147 

manner, and the amount of cutting, will, of course, 
depend on the circumstances of the case. If it be a 
firm root, broken low, so that to remove it, it is neces- 
sary to remove a portion of the alveolus, the gum 
should be dissected by one or two strokes of the 
knife from the alveolus, as deep as the forceps are to 
be applied, and as wide as is necessary to facilitate 
their application ; another cut should also be made 
by a single stroke of the knife in the direction of the 
length of the root, forming two small flaps of the 
dissected gum. The same operation should be per- 
formed on both the inner and outer sides of the root 
if forceps are to be used ; but if the case is one where 
the elevator is to be used, it will only be necessary 
to make the cuts on the outside and usually in but 
one direction. 

In performing the operation, any of the curious 
and even complicated lancets on which so much ex- 
uberant ingenuity and skill have been expended, can 
perhaps, with care, be made to answer the purpose as 
well, or nearly as well, as a simpler and more con- 
venient one ; and a plain bistoury or a scalpel, or 
a common penknife, will answer just as well. 

Although, as I have said, this operation is some- 
times necessary, and, in some cases, quite important, 



148 LANCING THE GUMS. 

yet, as a general rule, it ought to be entirely omitted ; 
and for various reasons. The first of which is, that 
in all ordinary cases, and with but very rare excep- 
tions — that is to say, in the extraction of all entire 
teeth and most roots of teeth — it is entirely useless. 

The resistance to be overcome, in extracting most 
teeth, is offered chiefly by the strength of the 
firm, dense membrane uniting their roots to their 
alveoli. It is therefore very evident that simply 
severing the gum from the neck of the tooth, to which 
it is usually not strongly attached ; and all of it that 
can be reached by any ordinary gum lancet, being of 
but small extent, can have but little influence in 
lessening the amount of force that it would require 
to extract them. A knife or gum lancet of any kind, 
cannot, by any possibility, be carried far enough be- 
tween the tooth and its alveolar process, to sever but 
a very small portion of the periosteum ; and it is very 
seldom that any one ever attempts to cut this mem- 
brane below the edge of the alveolus, unless it may 
be in the case of some loosened root which he intends 
to remove entirely with his knife 

The next great source of resistance in this opera- 
tion, and sometimes — not unfrequently — the source of 
greatest resistance, is the divergence or convergence 



LANCING THE GUMS. 149 

of their roots ; or the divergence of them for a portion 
of their length and their convergence the balance, re- 
quiring, if one or more of the roots do not first break, 
the removal of the bony septum between their roots, 
or the yielding of the parietes of the alveolar cells, 
or the springing of one or more of the roots, to admit 
of their removal, even if the periosteum were all 
scraped or macerated away. 

Corrugations in the roots, or crooks in them, exert 
a similar influence which no knife or lancet, however 
ingenious its form, can overcome. 

As already remarked, the attachment of the gum 
to the neck of a tooth is always but slight, and the 
extent inconsiderable ; so slight and so inconsiderable, 
that no operator or patient could possibly appreciate 
the difference in the amount of force required, or the 
pain experienced, whether the gums were cut or not. 
And besides this, the lancet in almost all cases is 
rendered entirely unnecessary by the fact, that 
properly constructed forceps — forceps fitted to each 
class of teeth on which they are to be applied, as 
described in the preceding chapter, will more easily 
and more thoroughly do it, and by the same move- 
ment that applies them to the tooth, than any lancet 
can be made to do it ; and with no more pain, if even 

13* 



150 LANCING THE GUMS. 

as much, in the application, than if the gum had been 
ever so freely lanced before. 

The operation of lancing the gum preliminary to 
extracting a tooth, is, in most cases, not only un- 
necessary, but decidedly objectionable for many 
reasons. 

It produces a great deal of unnecessary pain. 
With many patients, the dread of having the gums 
lanced is greater than that of having the tooth ex- 
tracted. Many timid and nervous patients can, by 
great effort, bring themselves to bear the infliction of 
one pain, but cannot a second. So, it is no uncommon 
thing for such an one to submit to having a gum 
lanced, and then to go away without having the tooth 
extracted ; but who would gladly have had it out, if 
it could have been done at once ; as it should have 
been. 

There is also some more danger from excessive 
hemorrhage when the gums are lanced than when 
they are not. A smoothly cut surface is more liable 
to bleed than a lacerated one. Therefore, in all 
cases, when it is necessary to extract a tooth, 
where a hemorrhagic diathesis is known to exist, 
or is mistrusted, the use of the lancet should be most 
sedulously avoided. I once knew a child to bleed to 



LANCING THE GUMS. 151 

death, in the hands of a very able surgeon, from 
simply cutting the child's gums to facilitate the erup- 
tion of its upper deciduous central incisors, though 
all known means were resorted to, to arrest the 
bleeding, from simple and long continued pressure, 
through all the range of styptics and- astringents 
from cold water to the actual cautery. 

The only argument known to me in favor of the 
general use of the lancet is, that by the adhesion of 
the gum to the neck of the tooth, sometimes the gum 
may be lacerated before that adhesion yields. If 
this were the usual result of neglecting to use the 
lancet, or if it were even a frequent occurrence, in 
consequence of such neglect, there would be force in 
the argument. But as that accident, in my expe- 
rience and observation, does not occur more than 
once in some thousands of times, and even then is 
the result of other carelessness — the good rule not 
being observed of operating no faster than the eye 
can follow, or than that the hand can be stayed at 
any stage of the operation, and, as already demon- 
strated, the forceps accomplish the object more effect- 
ually, without loss of time to the operator, with less 
pain, and without the interval of terrible suspense to 
the patient ; therefore, on the principle of " the 



152 LANCING' THE GUMS. 

greatest good to the greatest number," I cannot 
think it justifiable to torture the great multitude, in 
order to save an individual, or even a few persons 
from the possibly unnecessary slight infliction of 
pain that might thereby have been avoided. 

Have a gum-lancet, then ; let it be a good, plain, 
practicable instrument, but use it seldom. 



CHAPTER VI. 

ACCIDENTS ATTENDANT UPON THE EXTRAC- 
TION OF TEETH, AND THEIR REMEDIES. 

Although with the present improved styles, and 
new kinds of extracting instruments, and the im- 
proved manner of using them, accidents from this 
operation are much less frequent than formerly, still 
they will sometimes occur, even with the best in- 
formed and in the most skillful and careful hands, 
and frequently from no want of care or precaution 
on the part of the operator. 

These accidents may occur from undue excitement 
and uncontrollable restlessness on the part of the 
patient ; from malformation, or mal-arrangement of 
the teeth ; from some peculiar temporary condition, 
or from some inherent vice in the constitution of the 
patient ; and sometimes they may occur from care- 
lessness ! 

Among the most serious of these casualties, though 
fortunately far from being the most frequent, is ex- 
cessive hemorrhage. 



154 ACCIDENTS ATTENDANT UPON 

This, though sometimes the result of other causes, 
as the accidental fracture of the alveolus, by which 
the dental artery may have been wounded, or by an 
extensive laceration of the gums, is more commonly 
dependent on some morbid state of the system, tem- 
porarily changing the character of the blood, so that 
coagulation does not readily occur ; or producing 
such relaxation as to overcome the contractile power 
of the blood vessels ; or it may depend upon a con- 
stitutional hemorrhagic diathesis. Circumstances 
that cannot always be foreseen, or if foreseen, are 
not always within the control of the operator. 

If a hemorrhagic diathesis is known to exist in the 
patient, or in any of his family, and an operation 
becomes imperative, the utmost care should be used 
to avoid all incisions, lacerations, or other wounds 
that are not absolutely unavoidable, and especially 
in such cases should the use of the lancet be avoided. 
"A clean cut bleeds more freely than a lacerated 
wound." 

Dr. Taft, in his " Operative Dentistry," page 356, 
relates a case of a patient who very nearly lost his 
life by hemorrhage, from simply the lancing of his 
gums, preparatory to extracting a tooth, which he 
finally refused to have extracted. And I have already 



THE EXTRACTION OF TEETH. 155 

referred to a case which came under my own obser- 
vation, of an infant which bled to death from only a 
comparatively slight incision of its gums. 

If there be good cause to apprehend excessive 
bleeding from an enfeebled condition of the system, 
or from any other cause, and the nature of the case 
will admit of delay, a proper course of tonic treat- 
ment would, no doubt, be but a prudent precaution 
before preceding to operate. But unfortunately, in 
most cases, the liability to this accident cannot be 
foretold nor foreseen, therefore, when it does occur, 
our only recourse is to make the best reparation in 
our power, by taking advantage of all favorable cir- 
cumstances, and by availing ourselves of the best 
means known for arresting the flow of blood. 

The most common recourse in such cases is the 
application of cold water, or of some of the various 
astringents and styptics, or of compresses, or a com- 
bination of some or of all of these agents. 

Of the styptics and astringents, which have been 
extensively used in such cases, and with various suc- 
cess, the most common and effectual are tincture of 
nut-galls, powdered nut-galls, tannic acid, gallic acid, 
tincture of matico, the leaf of the matico rolled and 
inserted, oil of turpentine, nitrate of silver, spiders' 



156 ACCIDENTS ATTENDANT UPON 

web, and perchloride of iron, persulphate of iron, and 
some have resorted to the actual cautery, but that, I 
think, is always an operation of doubtful expediency. 
From my own observation of this searing process, 
which, however, has not been very extensive, its only 
effect is to form a crust or scab on the surface, which 
may temporarily arrest the flow of blood, but without 
any tendency to promote the formation of clot in the 
blood, or any permanent contraction of the vessels, 
and which is generally soon forced off by the action 
of the blood, leaving a larger bleeding surface than 
before, to be treated by other means. The milder 
means are generally more effective, and the after 
consequences far less serious. Sometimes, when the 
bleeding is quite persistent and very considerable, 
simply rinsing the mouth with a pretty strong solu- 
tion of tannin, or of powdered nut-galls, is sufficient 
to arrest the bleeding, especially if it proceeds from 
the capillary vessels ; but a more effectual way is to 
saturate pledgets of lint or of cotton in a solution or 
tincture of these substances, and having first cleared 
the sockets from which the tooth has been removed, 
as w r ell as may be, of all clots and blood, thrust them 
to the bottom of the bleeding cells with a probe, or 
other convenient instrument, and so keep on, adding 



THE EXTRACTION OF TEETH. 157 

pledget after pledget, till the cell is full. When 
matico or turpentine is used it should be done in 
the same manner. Sometimes it may be more con- 
venient to use the tannin or galls in powder than in 
solution or tincture, then the pledgets may be moist- 
ened in cold water, and rolled in the powder until it 
has taken up all it will contain, when the pledgets 
are to be packed into the bleeding cells as before 
described. When nitrate of silver is used, the most 
effectual way is to powder the salt and apply in that 
manner. 

If thus packing the cells does not prove sufficient, 
a few folds of lint or of common muslin may be placed 
above it, and over all place a metallic plate with 
clasps, or a bit of wire twisted together, so that its 

Fig. 36. . 



ends may form clasps to attach it to the adjoining 
teeth ; but, for want of such conveniences, or if there 
are no teeth adjoining, a cork may be cut, so as to 
leave one end of it the shape of the letter V, and 
placed over the compress and retained in place, and 
made to produce pressure by closing the jaws upon 
it, and keeping them closed, by passing a bandage 
14 



158 ACCIDENTS ATTENDANT UPON 

over the head and under the chin ; or the same thing 
may be effected by placing enough folds of the mus- 
lin above the bleeding part to meet the teeth or gums 
of the opposing jaw ; when the mouth is to be closed, 
and the bandage applied as before. When the pres- 
sure can be sustained by clasping to other teeth, it is 
to be preferred to bandaging, as it is much more com- 
fortable to the patient, as this leaves the jaws entirely 
unrestrained. 

When such means are necessary, as the bandaging 
together of the jaws, or the use of metallic plates or 
wires to produce pressure, they should be allowed to 
remain, and to sustain a steady pressure for several 
hours after the bleeding has ceased, and the pledgets 
with which the sockets have been filled, and more 
especially if there be a distinctly marked hemorrhagic 
diathesis, should be allowed to remain till the pro- 
cess of suppuration and granulation has removed, or 
at least loosened them ; and when removed, it should 
be done with great care and delicacy. 

If the case be urgent, and the above named reme- 
dies are not at hand, or do not effect the desired 
result, there is another article which is almost every- 
where to be found, which may be tried, and which in 
my hands once answered a most admirable purpose. 



THE EXTRACTION OF TEETH. 159 

This article is the common spider's web, or " cob- 
web." The only objection or inconvenience that I 
know of to the use of this article is, that my patient 
complained of pretty severe temporary pain from its 
application. In illustration of its effects, I will re- 
late a case : 

On a bitterly cold Saturday evening, in the winter 
of 1855, at about eight o'clock, a young woman of 
apparently about twenty years of age, of fully me- 
dium height, rather inclined to embonpoint, though 
not decidedly so, of graceful form, with a pleasant 
face and manner, and a complexion that, by gas- 
light, seemed very fair, but w T hich, by day-light, 
assumed a rather sallow, unhealthy kind of hue, 
came to my office, accompanied by a friend, and 
wished me to extract her first right lower molar tooth. 
After examination, I applied my forceps, and re- 
moved it, and with considerably less than the average 
amount of force required in such cases. She ex- 
pressed herself delighted at the ease with which I 
had taken it out, and was about to leave, but noticing 
that blood was flowing more freely than is usual after 
the extraction of a tooth, I suggested that she had 
better wait till the bleeding had ceased. After wait- 
ing for a considerable length of time — she rinsing 



160 ACCIDENTS ATTENDANT UPON 

her mouth freely with cold water meanwhile — and, 
seeing no abatement in the bleeding, I added tannin 
to the water, but w r ith no effect. I then plugged the 
alveolar cells with pledgets of cotton, previously 
moistened and rolled in tannin. This seemed to 
check the bleeding for a very short time, but did not 
entirely stop it even for a moment. I next applied 
pledgets of cotton, saturated with oil of turpentine, 
and after that with tincture of matico, but each with 
no more favorable result. I then resorted to nitrate 
of silver, which I applied by moistening pledgets of 
cotton and rolling them in the pulverized salt until 
they had taken up all they would contain, and with 
them firmly plugged the cells. To my great delight, 
after this application, the bleeding stopped, and my 
patient left my office about an hour and a half after 
the tooth was extracted. 

While she was in my office I learned from her and 
her female friend w r ho accompanied her there, and 
from others subsequently, that she was stopping with 
an irregular medical practitioner, for the purpose of 
being with, and nursing a younger brother, who was 
there to be treated for some scrofulous affection, and 
to be herself treated for leucorrhoea, or some other 
uterine difficulty, and was at the same time acting as 



THE EXTRACTION OF TEETH. 161 

a kind of sub-housekeeper for her medical adviser, a 
female physician. 

The next day, passing the doctress'(?) office, and 
feeling a great deal of anxiety about my patient of 
the night before, I called to inquire about her, and 
was told that my application had only restrained the 
hemorrhage for a few hours, and that she (the madam 
doctor) had stopped it by the application of " the 
scrapings of sole-leather. 5 ' Although I could not 
readily understand why the comparatively little tan- 
nin contained in the leather should have so much 
more effect than the pure tannin, which I had used, 
I was very glad to learn that the bleeding had been 
stopped, and by any means or by any hands. 

On the Tuesday afternoon following a messenger 
came, desiring me to come and see my patient as 
soon as possible, saying that she was again bleeding 
badly. 

Having already tried most of the well known pow- 
erful styptics in her case, (the perchloride of iron had 
not then been brought into notice,) and knowing that 
the " cobweb" had a very general, popular reputa- 
tion for arresting hemorrhage, I provided myself 
with that article before going to see my patient ; 
whom, when I went, I found lying in bed, with her 

14* 



162 ACCIDENTS ATTENDANT UPON 

head over its side, and bleeding badly; and she said 
she believed she was bleeding to death, and in that 
opinion there seemed grave reasons for concurring. 

First of all I directed her to assume a position as 
near erect as possible consistent with a sitting pos- 
ture. I then cleansed out the alveolar cells as well 
as I could, and plugged them with the cobweb ; and 
to my great gratification, found the bleeding was 
stopped by it immediately. 

On examining my patient, I found all her extremi- 
ties almost deathly cold ; her face flushed and her 
head hot. I ordered a hot pediluvium, to which, 
should be added a large quantity of ground mustard, 
and waited to see the faithful administration of it ; 
and that her feet were afterwards thoroughly rubbed 
and dried with coarse towels, thus doing all I could 
to equalize her circulation. I then directed her to 
take care to keep her extremities warm ; to keep her- 
self quiet ; to avoid all excitement and exertion — 
(that morning she had been exerting herself unu- 
sually in her domestic affairs) — and to send to me 
immediately on any recurrence of the bleeding. 

I did not see her again, but had a message some 
days after, that she had had no return of the hemor- 
rhage. 



THE EXTRACTION OF TEETH. 163 

From my success in that case, I would most 
strongly recommend — as strongly as I could from 
the experience of any single case — a trial of the cob- 
web in any case of intractable alveolar hemorrhage. 
It is always and everywhere attainable, and easy of 
application ; and although at the time of my trying 
it I was not aware that it had been used in such 
cases, I have since learned that others have used it 
w T ith marked success in similar cases, after having 
failed with all other available remedies. 

The only other case of alveolar hemorrhage that 
has ever given me any great degree of anxiety, out 
of a great many that have required some treatment 
to arrest an undue flow of blood, occurred in the 
autumn of 1847. This, also, I will relate, in ex- 
planation of the general plan and effect of treatment 
in such cases. The patient w r as a man of about 
twenty-eight or thirty years old ; of about medium 
height ; of rather a spare habit ; of active movements, 
and what by phrenologists would probably be called 
a nervous temperament, and by occupation a book- 
binder. 

The operation was the extraction of the root of a 
lower bicuspid. It was broken, or rather decayed 
away, quite to the gum, but still very firm in its 



164 ACCIDENTS ATTENDANT UPON 

socket, and it gave me some trouble to remove it ; 
but I succeeded finally, and very much to the satis- 
faction of my patient, and without any material 
laceration or injury to the gums ; neither was there 
any unusual degree of bleeding, either in time or 
quantity ; but, about six days afterwards, he returned 
to me bleeding most profusely, and said that he had 
been so bleeding for four or five hours. I cleaned 
out the socket, from whence the root had been re- 
moved, and plugged it with pledgets of cotton, pre- 
viously moistened with water and rolled in pulverized 
nut-galls, over which I placed a silver plate, confined 
to its place by clasping the contiguous teeth ; thereby 
securing steady and constant pressure. This arrested 
the bleeding for the time, and my patient went away, 
but in a few hours he returned bleeding as profusely 
as before. I then substituted pulverized nitrate of 
silver for the galls, and applied my compress as be- 
fore, and with more satisfactor}^ results, for it stop- 
ped the bleeding for the time, and in an hour or two 
afterwards I saw him on a stage coach, having started 
with his family to visit some friends in the country. 
As there was still a very slight oozing of blood, I felt 
considerable apprehension at seeing him go away 
from my immediate reach, but as I thought the change 



THE EXTRACTION OF TEETH. 1G5 

of air might be of service to him, and as I did not 
wish unnecessarily to alarm either him or his family, 
by expressing my fears, I thought it not best to op- 
pose his going. On his return, two or three weeks 
afterwards, he told me that the blood continued to 
ooze a little for an hour or two and then ceased ; after 
which he had no further trouble from it. 

Although the local treatment here indicated will 
claim our first, and perhaps chief attention, the state 
of the circulation and the general condition of the 
system must not be overlooked. In some cases, our 
hope of success must greatly depend on equalizing the 
circulation, and in such internal remedies as are known 
to give tenacity to the system, to increase the fibrine 
of the blood, and restore its quality of coagulation. 

Sec. 2. — Breaking of the tooth is one of the most 
common accidents attendant upon attempting to ex- 
tract. 

This may depend upon many circumstances, and 
may occur in any part of the tooth. With the use 
of the key this is a very common occurrence, and 
then occurs most commonly at their necks. In such 
cases the most certain way of avoiding this occur- 
rence is by avoiding the use of the key ! 



166 ACCIDENTS ATTENDANT UPON 

In using the forceps, too, it may occur at that 
point ; but when it does, it is, most commonly, by the 
use of a badly constructed, or by the bad application 
of a good instrument ; as explained when describing 
the proper application and use of the forceps. But 
again, this accident may occur with the best instru- 
ments, and in the most skillful hands, as when the 
tooth is so much decayed, or from other causes is so 
frail or brittle, as not to be able to sustain the pres- 
sure of the instrument required for its removal; or 
the patient may suddenly seize the hand of the ope- 
rator, and partially displace the forceps, or exert a 
force upon it, beyond what is required, thus crushing 
it, or by exerting a force in a wrong direction, and 
beyond the control of the operator. 

The roots of some teeth are so much curved, either 
outward or inward, as already noticed, or sometimes 
forming absolute hooks, that they cannot be removed, 
entire, without, at the same time, removing a portion 
of the alveolar process ; but in such cases the root is 
more likely to break than the process to give way. 
And as the crown of a tooth does not indicate the form 
of its roots, we can take no extra precautionary means 
to avoid the accident, and, even if they did ever so 
clearly indicate their form, we should be no better off. 



THE EXTRACTION OF TEETH. 



107 



When this accident occurs, the proper after treat- 
ment ^\i\\ depend very much on the condition of the 
tooth, and the place of the fracture. 

If the periosteum of the roots of such a tooth is 
inflamed, or if they are the cause of abscess, the most 
strenuous and persevering efforts, if necessary, should 
be resorted to for their entire removal. And the 
forceps for excising the alveolus, the elevator, or the 
gouge, may be resorted to as the case may require. 

If the tooth be an upper molar, broken at its neck 
so that the roots are left attached together, the gum 
Fig. 37. 




168 ACCIDENTS ATTENDANT UPOX 

should be dissected from the alveolus sufficiently to 
allow the forceps to be readily applied a line or two 
above the edge of the process, which, with forceps 
such as described, will usually afford sufficient hold 
to remove them. But if the common molar forceps 
cannot be made to effect the object, another kind of 
forceps with its external blade somewhat more ex- 
tended, more curved, and more attenuated, in short, 
constituting a simple hook, to be applied somewhat 
higher up in the bifurcation of the buccal roots, while 
its inner blade is like that of the common forceps, 
which is to be applied either to the palatine root or 
over the alveolus, will sometimes be found very use- 
ful. This, however, need but very rarely be resorted 
to, if the regular molar forceps are constructed as 
described. 

If a lower molar is broken above the bifurcation, 
the common lower molar forceps (having sharp curved 
points as described) should be applied, with their 
points on a line with the separation of the roots out- 
side of the alveolus, taking care first to dissect away 
the gum on both sides, so as to avoid lacerating or 
otherwise injuring it ; closing the forceps through 
the alveolus, and thus firmly seizing the roots and 
bringing away a small portion of the process with 



THE EXTRACTION OF TEETH. 169 

them. Sometimes, when the roots are very firmly 
set in the jaw, and there are indications that they 
cannot be brought away together, without injury to 
the jaw, it may be advisable to use the splitting for- 
ceps to separate them, when they may be brought 
Fig. 38. 




away singly, either w T ith the elevator, or the forceps 
which cut the alveolus and seize the root. Some- 
times they will be so much loosened in the act of 
splitting them apart, that they can be very readily 
picked away with lower root forceps. 

If the broken tooth be a single rooted one, and it 
cannot be removed by the elevator, then the forceps 
for cutting the alveolus should be used. Lower molars 
broken below their bifurcation, should be treated in 
the same manner. 

If the root of a tooth be broken and is sound and 
healthy, and not already loosened, and not more 
than three-fourths of its length remain in the jaw, 
and sometimes if even more than that remain, my 
practice is to let it remain ; knowing that before it 
15 



170 ACCIDENTS ATTENDANT UPON 

is likely to produce further trouble, its hooked point 
will have been absorbed, the alveolus also so much 
absorbed, and the whole root so far thrown up in its 
socket, by that process of nature which always strives 
to relieve herself of all useless or effete parts, that 
it can readily be apprehended and removed, by 
the elevator or the root forceps, and with compara- 
tively little pain to the patient or trouble to myself. 
But in such cases I am always careful to explain the 
circumstances to my patient, that he shall have no 
occasion afterward to tell me, or others, that I de- 
ceived him. 

It is a fortunate circumstance, too, that sound and 
healthy roots are much more liable to be broken and 
left in the jaw than diseased ones ; and from the 
fact that if abscess or inflammation have supervened, 
the bony socket has already, to some extent, at least, 
given place to the accumulation of pus, or to the 
thickened membrane, and thus left the root more or 
less loosened in its sockets. 

Sec. 3. Laceration of the gums, and such bruises 
as sometimes produce severe inflammation, and even 
sloughing, is by no means a very uncommon accident 
where the turn-key is in general use. To avoid .its 



THE EXTRACTION OF TEETH. 171 

frequent occurrence, as well as the occurrence of 
many other accidents, avoid the use of the key. 

It but very rarely happens, when forceps are used, 
that this accident occurs ; except where the alveolar 
process by being very thin, and very strongly at- 
tached to the tooth, is broken and brought away in 
the operation. In such cases, by the attachment of 
the gum to the alveolus, unless great care is used, 
pretty severe wounds may be inflicted. But the ordi- 
nary lancing of the gum is no safeguard against its 
occurrence. In some very rare cases, too, the gum 
may be so strongly attached to the neck of the tooth, 
as in the back part of the wisdom tooth, where the 
forceps or whatever other instrument is used, cannot 
come in contact with it to effect its separation, as 
to produce slight laceration before the attachment 
yields. 

The proper way to avoid this accident, in either 
case, is carefully to watch the operation, and never 
to operate so rapidly, or so roughly, as not to be able 
to stop before any serious injury has been inflicted. 
Thus, when the tooth has been started from its 
socket, and it is perceived that the alveolus is broken, 
and does not readily part from the gum, or if the 
gum adheres to the neck of the tooth, suspend its 



172 ACCIDENTS ATTENDANT UPON 

removal, and dissect away the gum from the bone, or 
from the tooth when the operation can be concluded 
without injury. 

I have oftener seen a strip of gum torn up, and 
even for a considerable distance across the roof of 
the mouth, in attempting to extract the root of a 
tooth with root forceps, whose points, when closed, 
nearly or quite, touched each other, and after the 
gums had been lanced, in the blood mistaking the 
edge of the gum for the root, seizing upon it, and 
pulling away suddenly, and thus tearing the gum, 
than by any adhesion to the neck of the tooth ! Due 
care will, of course, avoid such an accident as that. 

If the gum is, by any means, unfortunately torn 
so as to leave any loose flaps or shreds, they should 
be carefully cut away ; and for this purpose scissors 
are generally most convenient. 

Further treatment, beyond simply rinsing the 
mouth freely with cold water, if it feel hot and un- 
comfortable, will rarely be necessary, unless there 
happen to be a predisposition to hemorrhage, or 
to inflammation, when it may prove troublesome, 
like any other wound ; and will require to be treated 
by general principles, modified by the existing 
circumstances. 



THE EXTRACTION OF TEETH. 173 

Sec. 4. Fracture of the Alveolus. 

This accident too, at least to such an extent as to 
be of any considerable consequence, most frequently 
occurs from the use of the key ; and therefore requires 
us again unwillingly to speak of that instrument of 
torture, which, if we did not know was still very ex- 
tensively in use, not only in the country, but in the 
cities, and even by dentists as well as by physicians, 
we would not so much as once have alluded to it. 

Not unfrequently, with this instrument, where the 
fulcrum is allowed to rest too low upon the gum, or 
too high according as the case may be in the lower 
or the upper jaw — the side of the alveolar process is 
wrenched away to the extent of the width of the 
tooth, and the whole length of its roots ; and some- 
times to the extent of several teeth, thus depriving 
them of their support, and ultimately involving their 
loss, and the direct and permanent disfiguration of 
the sufferer. To avoid such accidents, I must say 
again, avoid the use of the key. 

'Tis true that this accident may, and even must to 
a limited extent occur, by the use of the best and 
most carefully used forceps ; but never to anything 
like the extent that is common in the use of the key. 
For example, in the removal of a tooth whose fangs 

15* 



174 ACCIDENTS ATTENDANT UPON 

converge so as to enclose the septum of bone between 
them, this portion of bone must come away with the 
the tooth, that is, if the tooth comes away entire ; but 
this, except as it sometimes requires a great deal of 
force to remove a tooth so situated, is of no conse- 
quence, and is hardly entitled to the designation of 
an accident. So, too, if the roots of a tooth are so 
greatly divergent that they cannot otherwise be 
drawn, a portion of the alveolar process may be 
cracked and forced away, or may be broken and 
brought away with the tooth. And sometimes, a 
very long single root, especially if it happen to be 
crooked, or of an uneven or corrugated surface, and 
its alveolus chance to be unusually thin, as is the 
case sometimes with the upper canine teeth, and more 
frequently than with any other class, in which cases 
the periosteal attachment may prove stronger than 
the alveolus, and a portion of it, and sometimes a 
pretty large portion of it, may be brought away. In 
such cases, however, the fault is not in the instru- 
ment, or necessarily in its application, or manner of 
using, but in the circumstances of the case. Then, 
if an accident so occurs, Ave can only do our best to 
retrieve and to excuse it. 

Although the operator may know that such an 



THE EXTRACTION OF TEETH. 175 

accident may not be of the least consequence, and 
sometimes even an advantage rather than an injury, 
it is not always easy to convince his patient of that 
fact ; and as such occurrences, however trivial they 
may be, are very apt to create distrust in the mind of 
the patient, as to the skill and ability of the operator, 
and sometimes even to affect his standing and useful- 
ness, when it can be done by quietly cleaving the 
fragment of bone from the tooth, and putting it to 
one side, it is perfectly justifiable and right for him 
to keep the knowledge of the fact to himself. This 
is at least safer for his reputation than to make a 
display of the case, to show the great difficulties he 
has had to overcome. 

Although I would observe a judicious caution in 
such cases, I would not compromise my conscience 
by a denial of the fact if directly asked the question 
whether the bone was broken, but would frankly ad- 
mit the fact, taking care at the same time not to 
make it appear worse than the nature of the case 
required, if no, or but little, injury were likely to re- 
sult; but, on the other hand, if trouble were likely to 
result from the accident, I would at once, whether 
asked or not, tell what had happened, and what re- 
sults might be expected. When the alveolus has 



176 ACCIDENTS ATTENDANT UPON 

been fractured, whether much or little, and there are 
any loose fragments remaining, they should be care- 
fully removed ; and if there are any sharp projecting 
points left, they should be removed with the cutting 
forceps, or some other convenient instrument ; other- 
wise they will be liable to produce irritation and in- 
flammation of the gums. 

This, in ordinary cases, is all the treatment that 
will be required ; but severer cases, if they occur, 
must be treated according to the general principles 
of surgery. 

I have quite recently known of quite an extensive 
fracture of the alveolus, including indeed, a consider- 
able portion of the superior maxillary bone, in the 
hands of a young operator, by the use of the eleva- 
tor, — the kind of elevator intended for the removal 
of roots. The case, as described to me, was this. 
A lady of about thirty years old had had bad teeth 
for many years. The crowns of nearly all her upper 
teeth were gone, while the roots still remained. 
Spme of them had been the cause of alveolar 
abscesses. The gums were in a very unhealthy 
condition from chronic inflammation and tumefac- 
tion. She had determined to have them all removed 
and to have artificial ones inserted in their place, 



THE EXTRACTION OF TEETH. 177 

and went to her dentist for that purpose. He had, 
without difficulty, removed some of them, when 
coming to the roots of the second right upper 
molars, he attempted to remove them also, with his 
elevator. To his surprise, he presently found that 
the decay had not proceeded quite far enough to 
separate the roots, and that he had, without the use 
of very much force, loosened them all, and with 
them a large portion of the alveolar processes ; but 
although these were loose, he could not remove 
them. Finally, with much embarrassment and anx- 
iety, on both his part and his patient's, he dissected 
away the gum, on both sides, and removed the mass, 
which proved to be the roots of the tooth, a portion 
of the alveolus about half an inch in length, includ- 
ing both walls and their septa, and enough of that 
portion of the maxillary bone which forms the floor 
of the antrum maxillare to make a very distinct 
opening into that sinus. 

A few days afterward the parts thus removed were 
shown to me. On examination, it was evident that a 
considerable portion of the outer wall of the alveolus 
had been removed by the effect of abscess, and necrosis 
had taken place in that wall and in the septa, and 
had extended nearly through a portion of the inner 



178 ACCIDENTS ATTENDANT UPON 

Avail or plate, leaving but a very thin portion of 
sound bone. 

This accident, though quite formidable in appear- 
ance, and very embarrassing to so young an opera- 
tor, was of no serious importance, and would most 
likely have occurred in the hands of any one, and 
by the use of any kind of an instrument. The 
wound healed kindly and well. 

As, apropos to the foregoing case, I was once 
called on by a physician to go with him and extract 
a troublesome tooth for one of his patients, who was 
suffering from a long lingering consumption. 

We found the patient in bed ; his whole mouth in 
a very bad condition. After examining the offend- 
ing tooth, I grasped it with my forceps, and with a 
very small degree of force removed, not that tooth, 
an upper molar, but the one next back of it, and 
their entire alveoli. On examination I found the 
bone necrosed and about as brittle and friable as so 
much dry hemlock bark. 

This accident, the fracture of the alveolar pro- 
cess, by patients, is most commonly denominated 
"breaking of the jaw," a term that sounds quite 
formidable; and true, fracture of the jaw really 
is quite a formidable accident, but it is one that I 



THE EXTRACTION OF TEETH. 179 

have never known to occur in extracting or in 
attempting to extract a tooth, but in one instance. 
That case I will here relate. 

Sec. 5. — Fracture of the Jaw from Extracting a 
Tooth. 

In the year 1845, Mr. L., living near Columbus, 
Ohio, sent his son, a boy of about eight years of age, 
to that city, to have his first permanent right lower 
molar tooth extracted. He went to some one prac- 
ticing there as a dentist, and submitted himself to 
the operation. What kind of an instrument was 
used I do not know, or in what manner the accident 
occurred — I should perhaps the rather say, how the 
crime was committed — I am ignorant; but, in ex- 
tracting the tooth, the operator broke the jaw en- 
tirely off, just in front of the tooth extracted. 
Either from not being aware that he had committed 
the injury, or from an entire ignorance of what was 
necessary to be done to retrieve it, or from the want 
of the courage to own it, he suffered the boy to leave 
his office with the fracture unreduced, and without 
informing him or his parents of the injury that had 
been committed. 

The bov returned to his home, with his tooth out, 



180 ACCIDENTS ATTENDANT UPON 

to be sure, but not in very pleasant plight, for he 
still suffered severe pain, and soon his face became 
very much swelled. This, however, w r as probably 
supposed to be a natural consequence of the opera- 
tion, or the result of " taking cold," and did not 
attract particular attention; or, at most, not enough 
to induce his parents to have it professionally ex- 
amined. 

About three months after the operation, the father 
removed to the vicinity of this city, where he had 
formerly lived, and then brought him to town for 
examination. 

I saw him at that time, though the case was not 
in my care. Then the face was very much swollen, 
and there was a large fistulous opening at the place 
of the fracture, with a discharge of fetid, sanious pus. 

The gentleman in whose charge the little patient 
was, from the great amount of swelling, and not mis- 
trusting that such an injury could have been inflicted, 
and so neglected, did not at that time discover the 
extent of the injury, but supposed it to be a case of 
very bad fracture of the alveolus. He removed some 
loose fragments of bone, and recommended some 
treatment to correct the fetor of the discharge, and, 
for the rest, trusted to time. He saw him occasion- 



THE EXTRACTION OF TEETH. 181 

ally, and directed such treatment as the case seemed 
to require. 

At the end of about three months from his first 
being brought to town, or about six from the time of 
the accident, the swelling had considerably subsided ; 
when, on a more critical examination, it was found 
that the jaw had not only been entirely broken off, 
but that it was now dead and loose in the flesh ! The 
broken end of it was, therefore, seized with a pair of 
forceps, where it presented at the fistulous opening, 
and, with but very slight force, was removed entire, 
from just in front of the first molar tooth to its articu- 
lation. I was present, too, at this operation. 

The wound after this healed kindly, but the now 
unopposed contraction of the muscles on that side so 
drew around the chin as to produce great and per- 
manent deformity. 

It may be proper further to state here, that a 
somewhat remarkable, or at least unexpected, feature 
of this case was, that in about six months from the 
removal of the dead bone, a new one was formed in 
its place ; but it extended in a straight line from the 
place of fracture to the articulation, without any an- 
gle. And what was a still more remarkable feature 

16 



182 ACCIDENTS ATTENDANT UPON 

in the case was, that not long after that time, a new 
tooth was found cutting from this new bone. 

Although this is an accident that but very rarely 
happens, and that ought never to happen, it is well 
to know that it may happen, because it has hap- 
pened. And if so unfortunate an occurrence should 
ever befall any one, he should immediately reduce 
the fracture, and take the proper means to keep the 
fractured ends of the bone in perfect apposition ; or, 
if not competent to treat the case himself, he should 
at once call the aid of a competent surgeon. 

Sec. 6. — Extraction of a Wrong Tooth. 

This is an accident, of not very frequent occur- 
rence, but still more frequent than it should be, for 
it occurs not only sometimes unavoidably, and some- 
times by mistake, that may be excusable, but some- 
times by sheer carelessness, for which there is no 
justification or excuse. 

Sometimes a patient applies to have a perfectly 
sound and healthy tooth taken out, saying that the 
pain in it is intolerable, a-nd insists on having it out, 
when the seat of the pain is in a contiguous tooth, 
or even in one quite remote from it ; or, it may be, 
that the origin of the pain is in no w T ay connected 



THE EXTRACTION OF TEETH. 183 

with the teeth. One unobservant or unacquainted 
with the pathology of toothache would, under such 
circumstances, be very likely to rely on the impres- 
sions of his patient, and to be guided by his wishes, 
and take out the tooth pointed out to him. This, 
too, would be an inexcusable error, for no one ought 
ever to pretend to extract teeth, until he can by his 
own examination, more certainly tell what tooth 
aches than can his patient. 

But sometimes, as for example, it happens that a 
molar tooth has a small but deep decay near the 
centre of one of its approximal surfaces, and where, 
from its position, neither the eye nor an instrument 
can reach to explore the cavity. In such a case we 
must mainly rely on the impressions of the patient, 
and if they are wrong, we shall be liable to take out 
the wrong tooth. This, when no care on the part of 
the operator has been omitted, is an excusable 
mistake. 

Again, it sometimes happens that when a molar is 
to be extracted, the root of a bicuspidatus adjoining 
it may be partially imbechded in a groove in the root 
of the molar, and the roots of the molar by being at 
the same time considerably divergent, may extend 
partially under that of the bicuspidatus, when, on 



184 ACCIDENTS ATTENDANT UPON 

removing the molar, the bicuspidatus is of necessity 
brought away with it. But as no amount of care 
could predetermine their relation, and no skill could 
avoid the result, the operator is not to be blamed ; 
and all that could then reasonably be asked or ex- 
pected of him w 7 ould be that he make the best repa- 
ration in his power. 

This last named accident has twice occurred in my 
ow r n practice. In extracting a molar, whose roots 
were divergent and deeply grooved on their outer 
approximal surfaces ; a bicuspidatus, whose root was 
partially imbedded in the root of the molar, was 
brought away with it ; and when the instrument was 
fairly and perfectly placed on the molar, w r hich was 
so much larger than the other tooth that the instru- 
ment did not, and could not in the least, impinge 
upon, or even touch the smaller tooth. 

In such cases, both for the satisfaction of the 
patient, and to protect the reputation of the operator, 
the teeth should at once be shown to the patient, and 
the circumstances explained and illustrated. 

But when from any cause, whether justifiable or 
unjustifiable, a tooth has been taken out that ought 
not to have been, a very important question arises, 
to wit : what shall be done with it ? To this question 



THE EXTRACTION OF TEETH. 185 

different answers have been given. But, from the 
few eases that I have myself tried, a few that have 
come under my observation in the hands of others, 
and several reports of other well attested cases, I 
could feel justified in taking, or in recommending 
but one course ; and that course would be, immedi- 
ately to replace the tooth as nearly as possible in its 
original position, and then require the patient to 
close the jaws firmly, till all the other teeth come 
fairly in contact ; thus assuring myself that the tooth 
did not stand too prominent, and would not ulti- 
mately interfere with the perfect closing of the jaws, 
or, in other words, that it was perfectly in its place. 
In almost every case, probably in every case where 
the circumstances are not particularly unfavorable, 
where this course is pursued, it will be found that 
in a few days the tooth has become re-attached, by 
its periosteum to its socket, and is fully restored to 
usefulness ; the only inconvenience experienced, 
having been some soreness ; enough, perhaps, to re- 
quire the use of such food as would not require much 
mastication for a portion of the time. I have never 
vet seen a case of the kind fail ; but it is true that 
the few cases I have seen were favorable cases. But, 
although in a generally unhealthy state of the mouth, 

16* 



186 ACCIDENTS ATTENDANT UPON 

or of the system it might fail, and would be more 
likely to fail than under more favorable circumstances, 
I would still most strongly recommend a trial of it 
in all cases; for, in surgery, sometimes w r hat seem to 
be very unpromising cases, turn out even unex- 
pectedly well. 

Sec. 7. Dislocation of the Lower Jatv. 

In some persons with very lax muscular and liga- 
mentous fibre, and, especially, if they have large 
mouths, this is an accident very easily produced. 
Yawning, only, sometimes produces it, and when it 
has once occurred it is more likely to re-occur than 
before ; and it, probably, more frequently happens 
by the patient suddenly opening the mouth to its 
fullest capacity to admit of an operation, than by the 
operation itself. 

In the use of forceps, if the chin is firmly grasped 
by the left hand, as it always should be, the jaw re- 
ceives such support, as to render it almost impossible 
to dislocate the jaw. In using the key, the chin 
cannot be thus seized and supported, and if the ful- 
crum of that instrument be next the tongue, as is the 
most common way of applying it, a severe strain is 
made on the articulation of the opposite side of the 



THE EXTRACTION OF TEETH. 



187 



jaw, which may produce, and often has produced, 
this accident. 

This accident can only be produced by the de- 
pression of the chin, thus turning the condyle or 
condyles, as the luxation may happen to be of 
one or of both articulations out of its socket, 
and lodging it in front and above the glenoid fossae 
with which it articulates. The mouth will then be 
opened to its fullest extent, the jaw fixed, and the 
countenance expressive of great anxiety, as illustrated 



in Fig. 39. 



Fig. 39. 




From a study of the action of the muscles which 
close the jaws, it will at once be seen that the force 



188 ACCIDENTS ATTENDANT UPON 

required to reduce the luxation, must be directly 
downward; and when the jaw has been forced down 
till the condyles are opposite their sockets, the mus- 
cles themselves will carry them backward with a 
sudden snap, into their proper places. 

The necessary force to effect this object, can most 
readily be applied by placing the thumbs on the 
posterior teeth, or if they are gone, by placing them 
as far back as may be on the jaw, using them as a 
fulcrum, while, with the fingers, the chin is forcibly 
raised. 

Some recommend the use of corks or other sub- 
stances, placed between the molar teeth as fulcrums, 
instead of the thumbs, but they require more display, 
are less readily managed, and are less effective. But 
when the. thumbs are used, it will be but a prudent 
precaution to wrap them with napkins or any other 
convenient material, lest in the sudden closure of the 
jaw they be bruised by the teeth. 

In the dislocation of the lower jaw, as in dislocation 
of all other joints, there must necessarily be more 
or less straining, or even rupture of the capsular 
ligaments ; therefore, till the parts have had time to 
recover their strength, after such an accident, care 
must be used to avoid opening the mouth further than 



THE EXTRACTION OF TEETH. 189 

is necessary for the reception of soft food, lest the 
accident be reproduced ; and to guard against this, 
it may be well to affix a bandage over the head, and 
under the chin so as to restrain the motions of the 
jaw within certain limits. 

Such bandaging too, will be a prudent safeguard 
in preparing to extract a tooth for one in whom the 
accident is known previously to have occurred, for, 
as already remarked, when this accident has once 
occurred, it is more easily reproduced than before. 

4 Sec. 8. Syncope, or Fainting. 

With some, syncope seems almost to be a habit, 
they being subject to it from the slightest causes, 
and on almost all occasions, as from sudden sensa- 
tions of pain or fear, sorrow or joy. Some are liable 
to it under certain conditions of the system, but never 
otherwise. There are no distinctive indications 
known to the writer, by which to determine who are 
liable to it, or under what circumstances. Sometimes, 
the apparently healthy and strong are very liable to 
it, while others that are feeble and sickly never faint, 
and the reverse. 

I once saw a healthy, strong, robust and brave 



190 ACCIDENTS ATTENDANT UPON 

man faint entirely away, from the slight scarification 
of the arm in the operation of vaccination. 

This accident is quite as likely to occur from the 
dread of the operation, as from the operation itself. 
It sometimes occurs simply from a sight of the in- 
struments to be used, and frequently from the sight 
of blood ; therefore, no unnecessary display of instru- 
ments should ever be made, and what are necessary 
should always be clean and in good order, ready for 
immediate use ; and no blood should, in any way be 
drawn, if it can be avoided, until the tooth is ex- 
tracted ; and after one operation, all instruments and 
vessels should be carefully cleansed and wiped, from 
all stains or appearance of blood, before another is 
undertaken. 

A rough, and unfeeling manner sometimes causes 
fainting, therefore kindness and gentleness of man- 
ner, especially with female patients, should most 
sedulously be cultivated and observed. 

" It" (syncope) " consists in an intermission of the 
heart's action, and consequently irregularity of the 
circulation of the blood accompanied with a tempo- 
rary suspension of the functions of the brain, and a 
loss of consciousness." The first indication of its 



THE EXTRACTION OF TEETH. 191 

approach generally is, that the patient complains of 
nausea, and a ringing in the ears, accompanied with 
pallor of the countenance, and partial or complete 
prostration of muscular energy, with irregular or 
suspended respiration. 

The readiest way of restoring a patient from syn- 
cope, is to place him in a horizontal position, free 
from all compression and restraint of the neck, chest 
and respiratory organs ; admit a full and free supply 
of fresh air ; apply aqua ammonite or other volatile 
stimulants to the nostrils, or dash cold water in the 
face, with friction of the extremities. Or, what I 
have frequently found more effective than any other 
remedy, especially if the patient be not habituated 
to its use, is to give a teaspoonful or two of brandy 
with about an equal quantity of cold water. Much 
more than this, to one accustomed to its use, will be 
necessary. 

Sec. 9. — Hysteria. 

With those subject to this disease, the dread or 
the shock of this operation is frequently sufficient to 
develop it. It has occurred several times in my own 
practice from the dread of having a tooth extracted, 
and a few times from alarm at the peculiar sensation 



192 ACCIDENTS, ETC. 

produced by the first sensible effects in inhaling 
ether ; and I have seen it from these causes in the 
hands of others. 

The symptoms are very various. At different 
times simulating almost all manner of diseases. 
Among the most common, however, are a sense of 
suffocation or choking — the " globus hystericus" of 
the old writers — apparent syncope, and spasms or 
cramps of the muscles of the abdomen, chest, neck, 
and limbs, and especially of the hands and fingers, 
which are frequently as rigid as if they were frozen, 
all accompanied with a sensation of great fatigue, 
which they often express by saying, " I am so tired." 
This complaint occurs much more frequently with 
females than with males. 

The most effective remedy usually is either some 
anodyne — the most satisfactory of which I have ever 
tried being small doses of the tincture of assafoetida — 
or entire neglect. The appearance of the patient, to 
one who has never before seen the affection, is often 
truly alarming ; but the anxiety and sympathy of 
friends or attendants almost always aggravate the 
complaint. Fortunately the prognosis is nearly 
always favorable, and time and proper neglect will 
generally at least afford relief. 



CHAPTER VII. 
ANAESTHETICS. 

A work of this kind, at the present day, might 
seem to be incomplete without something being said 
on anaesthetics. But on this subject I have but little 
to say. 

In all serious surgical operations, and especially 
where "the shock of the operation" is liable to en- 
danger the life of the patient, the administration of 
some anaesthetic is not only justifiable, but the ne- 
glect to use it, unless seriously objected to by the 
patient or his friends, would be highly reprehensible ; 
or in cases of difficult parturition, where the pains 
and fatigues are more dangerous than the anaesthetic 
agent — and here I will remark parenthetically, that 
from the best information that I can gather on this 
subject, that patients already suffering severe pain 
are less liable to sink under the use of such agents, 
than under other circumstances — it ought not to be 
withheld. But, in the operation of extracting the 
17 



194 ANESTHETICS. 

teeth, I avoid them generally ; and, indeed, in all 
cases, unless strongly urged, and for these reasons. 

There is no serious danger from the shock of the 
operation ; at the most, I have certainly never heard 
of death resulting as the immediate effect of extract- 
ing a tooth ; and it is usually, when skillfully per- 
formed, an operation of very short duration. 

Experience has proved that there is some danger 
from the use of some of the agents used to produce 
anesthesia. Many lives have been lost, both in this 
country and in Europe, from the effects of chloro- 
form. Sulphuric ether is disagreeable to some, very 
disagreeable to others, and to others again uncertain 
in its effects, producing only excitement without an- 
aesthesia. I would sooner endure the pain of extrac- 
tion than the discomfort of inhaling ether. 

Probably very few persons operate as carefully, 
when their patients are under the influence of an 
anaesthetic, as when not, and for two reasons. First, 
they are likely to operate hurriedly, lest the in- 
fluence of the anaesthetic pass off before the opera- 
tion is completed ; and, second, one is not apt to feel 
the same amount of responsibility and need of care 
when he knows his patient feels no pain, as under 
other circumstances ; therefore accidents are more apt 



ANAESTHETICS. 195 

to occur with the use of these agents than without 
them. 

Within the last few years various substances and 
appliances have been recommended, for the purpose 
of producing " local anaesthesia." The most promi- 
nent of these are: chloroform, applied directly to the 
part; various freezing mixtures, similarly applied, 
and electricity. But from my own observation, and 
the best information I can obtain, they are not en- 
titled to any serious consideration. 

The smarting from the application of the chloro- 
form is quite as severe as the pain of the extraction, 
and is, therefore, at best, but a change of disagreea- 
ble sensations, a kind of translation of pains ; if, in- 
deed, it at all relieves the pain, and is not rather a 
smart, superadded to the pain. 

The freezing mixtures are totally inadmissible in 
most cases, or except where the tooth to be extracted 
stands isolated from the rest, and they are always 
liable to produce severe injury, and even sloughing, 
of the gums and surrounding parts.* 



* I have quite recently been shown, by a dentist of Pittsburgh, Pa., 
a part of an apparatus for conveying cold to a tooth, so as to prevent 
the sense of pain during extraction; which was represented to me as 
producing the effect most perfectly and without any danger of acci- 
dent from its use. But the apparatus being, as was alleged, about 



196 ANAESTHETICS. 

The electricity, in many cases where its use would 
be most desirable, only intensifies the pain ; and, in 
all the rest, probably only diverts the attention, by 
producing a different kind of pain from that of the 
operation to be performed. 

Of all the agents used for producing insensibility 
to pain, at present known, chloroform and ether are 
probably the only two to be relied on, and these 
only by producing general anaesthesia ; and of these 
two, from its milder action and greater safety — 
nearly if not quite all the lives that have been lost 
by them in this country, at least, having been from 
chloroform — I greatly prefer the ether ; though, 
what in some cases is better, and perhaps as good in 
all, is a mixture of the two, in about the proportion 
of four parts of ether to one part of chloroform. 

The most convenient, and probably the safest way 
of administering either of them, is by saturating a 
napkin or a concave sponge with the material and 
holding it before the face, but not so closely at first 
as to exclude the free admission of atmospheric air 
from the lungs ; meantime closely watching the effect, 



to be patented, and the holder being under bonds not to exhibit it till 
the patent was secured, of course I could not be favored with an ex- 
hibition. 



ANAESTHETICS. 197 

and if no untoward circumstances transpire, after- 
ward bringing it closer and administering it more 
freely, but at no time entirely excluding the air ; and 
so continue to administer it till the desired state of 
insensibility is produced. 

If at any stage of the administration the patient 
begin sensibly to sink, as indicated by any material 
diminution, in either the force or frequency of the 
pulse, or of pallor of the countenance, the adminis- 
tration should immediately cease and restoratives be 
resorted to. Of these, I have seen cold douches to 
the head, volatile stimulants applied to the nose, and 
if the patient be not past the ability to swallow, a 
few drachms of brandy act very efficiently in re- 
storing sensibility. In more urgent cases, electri- 
city, insufflation, or other means of artificial respira- 
tion should be resorted to, and without delay. But 
with pure sulphuric ether, and with due care in its 
administration, very little danger need ever be ap- 
prehended. 

I must here digress enough to say that in my un- 
prejudiced opinion, formed from all the testimony 
that has been offered on the subject, the credit of 
introducing anaesthetics for the prevention of pain in 



198 ANESTHETICS. 

surgical operations is justly due to the late Dr. Horace 
Wells, of Connecticut. 

Before dismissing this subject, I cannot too strongly 
caution every one who administers either chloroform 
or ether, and whether separately or mixed, against 
ever administering it to any female patient, except 
in the presence of some reliable third person. And, 
although, from my own knowledge and observation, I 
could offer reasons to enforce the necessity of this 
caution, the records of some of our courts of justice 
afford sufficient proof of its necessity without further 
argument. 






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